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Background: In free jejunum transfer, knowing the ischemic tolerance time of the jejunum is crucial. It helps determine the need for reharvesting if an unexpected situation prolongs the ischemic time. The current ischemic tolerance time in humans is unknown. We investigated the relationship between ischemic time and postoperative complications in head and neck cancer patients who underwent free jejunum transfer., Methods: The study included 76 patients with available medical records out of 103 patients who underwent free jejunum transfer between 2009 and 2023. The association between the surgical procedure, including ischemic time, and patient's background, and flap engraftment, stenosis of the intestinal anastomosis, the swallowing function, and other complications was investigated., Results: The ischemic time for jejunal flaps ranged from 1 h 24 min to 6 h, with a mean of 197 ± 55.5 min. In 72 patients, the jejunum was successfully engrafted, but vascular occlusion occurred in another four patients. In three of these patients, jejunal necrosis occurred, and there was no specific trend in ischemic time. Stenosis of the intestinal anastomosis occurred in 17 cases (22%), with ischemic time (≥3 h) and age (≥75 years) being significant factors for stenosis (ischemic time: 30% vs. 10%, p = 0.048, age: 50% vs. 15%, p < 0.01). No significant correlations were observed with other complications or the swallowing function., Conclusion: There was no specific trend between ischemic time and jejunal survival rate, indicating that an ischemic time within 6 h may not have affected engraftment. Although we have recently performed intestinal anastomosis prior to vascular anastomosis, the choice of surgical technique should be adapted to the patient's age and background., (© 2024 Wiley Periodicals LLC.)

Osteotomy is often necessary for the repair of post-traumatic nasal bone deformities. Typically, tools such as chisels are used for osteotomies; however, we performed osteotomies using Kirschner wires without making a skin incision. Between April 2011 and July 2022, we performed rhinoplasty with external perforated osteotomy using Kirschner wires in 13 patients with post-traumatic nasal bone deformities (9 males and 4 females; mean age, 34 years, range 12-51 years), all of whom exhibited improvement, with only one case showing mild residual cosmetic deformity. None of the patients requested further revision, and all were satisfied with their functional results. The non-incisional external perforated technique is a reasonable method that allows for bone osteotomies along the fracture line and is well-controlled, predictable, and reproducible., (Copyright © 2024 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Physiatrists play a vital role in post-stroke dysphagia management not only by providing guidance on the risks, benefits, and efficacy of various treatment options but also as advocates for patients' independence and quality of life. While swallow study results are often discussed broadly by acute stroke clinicians as "pass/fail" findings, physiatrists need a more nuanced working knowledge of dysphagia diagnosis and treatment that encompasses swallow pathophysiology, targeted treatment strategies, and prognosis for recovery. To that end, this review summarizes current clinical practice guidelines on dysphagia, nutrition and oral care, risks and benefits of differing enteral access routes, prognostic factors, and approaches to rehabilitation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The aim of the study is to evaluate the safety and efficacy of a physiatrist-led clinical pathway to expedite rehabilitation transitions for stroke patients with dysphagia requiring nasogastric tube or percutaneous endoscopic gastrostomy., Design: This is a retrospective single-center observational study in 426 adults with stroke and dysphagia admitted to the acute hospital. Physican Medicine and Rehabilitation (PM&R) was consulted to determine dysphagia prognosis and candidacy for rehabilitation admission with nasogastric tube or percutaneous endoscopic gastrostomy. The proportion of patients accepted with nasogastric tube versus percutaneous endoscopic gastrostomy, progression to total oral diet during rehabilitation, and lengths of stay were tracked., Results: The rate of recovery to total oral diet for patients accepted with nasogastric tube was 38/44 = 86.3% versus 29/75 = 38.6% with percutaneous endoscopic gastrostomy. There was a significant difference in mean time to total oral diet with nasogastric tube (20.37 days) versus percutaneous endoscopic gastrostomy (34.46 days): t (43) = 4.49, P < 0.001. The acute hospital length of stay was significantly shorter with nasogastric tube (12.9 days) versus percutaneous endoscopic gastrostomy (20.4 days): t (117) = 4.16, P < 0.001. Rehabilitation length of stay did not differ significantly between groups (26.9 vs. 32.0 days)., Conclusion: Physiatrist-led initiatives to evaluate stroke patients with dysphagia can expedite rehabilitation transitions, prevent unnecessary invasive procedures, and reduce acute hospital length of stay., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: The regeneration of adipose tissue in patients after breast cancer surgery would be desirable without the use of growth factors or cells to avoid potential recurrence and metastasis. We reported that prolate spheroidal-shaped poly-L-lactic acid (PLLA) mesh implants of approximately 18-mm polar diameter and 7.5-mm greatest equatorial diameter containing collagen sponge (CS) would be replaced by regenerated adipose tissue after implantation, thereby suggesting an innovative method for breast reconstruction. Our study aimed to evaluate the adipose tissue regeneration ability of implant aggregates in a porcine model., Methods: We prepared implant aggregates consisting of thirty PLLA mesh implants containing CS packed in a woven poly (glycolic acid) bag. The implant aggregates were inserted under the mammary glands in the porcine abdomen for a year. Single and double groups were classified by inserting either one or two implant aggregates on each side of the abdomen, respectively., Results: In both groups, the volume of the implant aggregates decreased over time, and the formation of adipose tissue peaked between 6 and 9 months. Histologically, the formation of adipose tissue was confirmed in the area that was in contact with native adipose tissue., Conclusions: Our implant aggregates could induce the autologous adipose tissue after long term implantation in vivo , without the use of any growth factor or cell treatment, presenting a potential novel method of breast reconstruction., (© 2023 The Japanese Society for Regenerative Medicine. Production and hosting by Elsevier B.V.)

Impairment of hand function greatly affects the independence of a human being. Proper assessment of hand function before and after any treatment for functional restoration is important to decide better treatment strategies. Despite traditional techniques of hand function evaluation, individual joint based assessment is vital to better track the details of the hand function. Current clinical assessments with goniometers are labour intensive, cumbersome and highly depend on the skill level of the practitioner. This study introduces an active range of motion (AROM) measurement system to measure individual range of motion of finger joints using an optical sensor. The proposed method is highly efficient, and the results demonstrated that the measurements are instant, repeatable and can successfully be employed in a clinical setup for patient evaluations.Clinical Relevance-Closely working with clinician to develop rehabilitation systems, we have identified that the assessment of patient hand functions is time consuming, and accuracy can be depended on the skill level of the practitioner in measuring joint range of motions (ROM). System introduced in this study can measure the joint AROMs instantly and independent of the practitioner's skill level and hence can provide a reliable, repeatable assessment of patient's hand function.

Purpose: Gastrointestinal cancer can be treated using a flexible endoscope through a natural orifice. However, treatment instruments with limited degrees of freedom (DOFs) require a highly skilled operator. Articulated devices useful for endoluminal procedures, such as endoscopic submucosal dissection and biopsy, have been developed. These devices enable dexterous operation in a narrow lumen; however, they suffer from limitations such as large size and high cost. To overcome these limitations, we developed a 2.5-mm articulated forceps that can be inserted into a standard endoscope channel based on a compliant mechanism., Methods: The compliant mechanism allows the device to be compact and affordable, which is possible due to its monolithic structure. The proposed mechanism consists of two segments, 1-DOF grasping and 2-DOF bending, that are actuated by tendon-sheath mechanisms. A prototype was designed based on finite element analysis results., Results: To confirm the effectiveness of the proposed mechanism, we fabricated the prototype using a 3D printer. A series of mechanical performance tests on the prototype revealed that it achieved the following specifications: (1) DOF: 1-DOF grasping + 2-DOF bending, (2) outer diameter: 2.5 mm, (3) length of the bending segment: 30 mm, and (4) range of motion: [Formula: see text] to [Formula: see text] (grasping) and [Formula: see text] to [Formula: see text] (bending). Finally, we performed a tissue manipulation test on an excised porcine colon and found that a piece of mucous membrane tissue was successfully resected using an electric knife while being lifted with the developed forceps., Conclusion: The results of the evaluation experiment demonstrated a positive feasibility of the proposed mechanism, which has a simpler structure compared to those of other conventional mechanisms; furthermore, it is potentially more cost-effective and is disposable. The mechanical design, prototype implementation, and evaluations are reported in this paper., (© 2022. CARS.)

Background: Giant congenital melanocytic nevi are large skin lesions associated with a risk of malignant transformation. The authors developed a novel treatment to reconstruct full-thickness skin defects by combining an inactivated nevus as the autologous dermis and a cultured epidermal autograft. The first-in-human trial of this treatment was performed., Methods: Patients with melanocytic nevi that were not expected to be closed by primary closure were recruited. The full-thickness nevus of the target was removed and inactivated by high hydrostatic pressurization at 200 MPa for 10 minutes. The inactivated nevus was sutured to the original site, and a cultured epidermal autograft was grafted onto it 4 weeks later. Patients were followed for up to 52 weeks., Results: Ten patients underwent reimplantation of the pressurized nevus, and one patient dropped out. The recurrence of nevus at 52 weeks was not detected by pathological diagnosis in any patients. The L* value at 52 weeks was significantly higher than that of the target nevus. One patient received skin grafting due to contracture of the reconstructed skin. The epithelized area of the reconstructed skin, as the percentage of the original target nevus, was 55.5 ± 19.4 percent at 12 weeks and 85.0 ± 32.4 percent at 52 weeks., Conclusions: The inactivated nevus caused inflammation and contracture for several months. However, no recurrence was observed, and combination therapy using an inactivated nevus with a cultured epidermal autograft may therefore be a novel treatment of giant congenital melanocytic nevi., Clinical Question/level of Evidence: Therapeutic, IV., Competing Interests: Disclosure:The authors declare no conflicts of interest in association with the present study. The authors have no financial interests to disclose., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Worldwide, over 50 million people suffer from persistent hand impairments after stroke or spinal cord injury (SCI). This results in major loss of independence and quality of life. Robotic hand exoskeletons can compensate for lost motor function and assist in grasping tasks performed in everyday activities. Several recent prototypes can partially provide this assistance. However, it remains challenging to integrate the dexterity required for daily tasks in a safe and user-friendly design that is acceptable for daily use in subjects with neuromotor hand impairments. We present the design of RELab tenoexo; a fully wearable assistive soft hand exoskeleton for daily activities. We present sleek mechanisms for a hand module that generates the four most frequently used grasp types, employing a remote actuation system that reduces weight on the hand. For optimal assistance and highest adaptability, we present various design and control options to customize the modular device, along with an automated tailoring algorithm that allows automatically generated hand modules for individual users. Mechanical evaluation shows that RELab tenoexo covers the range of motion and the fingertip forces required to assist users in up to 80% of all grasping activities. In user tests, we find that the low weight, unintrusive size, high wearing comfort, and appealing appearance are beneficial for user acceptance and usability in daily life. Finally, we demonstrate that RELab tenoexo leads to an immediate improvement of the functional grasping ability in a subject with SCI.

Among promising solutions for tissue repair and wound healing, mesenchymal stem (or stromal) cells (MSCs) have been a focus of attention and have become the most clinically studied experimental cell therapy. Recent studies reported the importance of apoptosis in MSC-mediated immunomodulation, in which apoptotic MSCs (apoMSCs) were shown to be superior to living MSCs. Nowadays, high hydrostatic pressure (HHP), a physical technique that uses only fluid pressure, has been developed and applied in various bioscience fields, including biotechnology, biomaterials, and regenerative medicine, as its safe and simply operation. In the current study, we investigated the impact of HHP treatment on human bone marrow-MSC survival and proliferation. Based on the detection of executioner caspase activation, phosphatidylserine exposure, DNA fragmentation (TUNEL) and irrefutable ultrastructural morphological changes on transmission electron microscopy (TEM), our data revealed that HHP treatment induced complete apoptosis in MSCs. Notably, this technique might provide manipulated products for use in cell-based therapies as manufacturing capability expands. We hope that our findings will contribute to the improvement of MSCs or EVs in translational research development. Graphical Abstract.

Introduction: Curettage and dermabrasion are effective in the treatment of giant congenital melanocytic nevi (GCMN); however, local infection and hypertrophic scar formation are major issues. Thus, we applied cultured epithelial autografts (CEA) on skin defects after curettage or abrasion of GCMN and assessed the postoperative outcomes., Methods: Seven nevi lesions of five patients (aged 3 months to 24 years) were treated with CEA after curettage or abrasion with a dermatome or a surgical bar, respectively. We assessed the postoperative outcomes, including CEA take ratio, erosion and/or ulcer formation in the acute phase, hospitalization days, Vancouver scar scale, and color improvement one year after the operation. In addition, a histological evaluation of a skin biopsy was performed over one year after the operation., Results: The CEAs took well on the wound, and the wound surface was mostly epithelized by postoperative day 7 in all cases. While hypertrophic scar formation and slight pigmentation were observed in some lesions, the color was improved in all of the treated lesions. Histopathological examination revealed that the regenerated epidermis had stratified keratinocytes with rete ridges, and the dermal layer without nevus cells regenerated above the remaining dermis layer., Conclusions: In this study, we found that early epithelialization and regeneration of the dermal layer was achieved after the application of CEA, suggesting that CEA could be an effective option after curettage or abrasion of GCMN., Competing Interests: The authors (MS and NM) were financially supported by Japan Tissue Engineering Co., Ltd. (J-TEC) for their collaborating research. However, the company did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript., (© 2021 The Japanese Society for Regenerative Medicine. Production and hosting by Elsevier B.V.)

Background: Giant congenital melanocytic nevi (GCMN) treatment remains controversial. While surgical resection is the best option for complete removal, skin shortage to reconstruct the skin defect remains an issue. We report a novel treatment using a high hydrostatic pressurization (HHP) technique and a cryopreservation procedure. However, cryopreservation may inhibit revascularization of implanted nevus tissue and cultured epidermal autograft (CEA) take. We aimed to investigate the influence of the cryopreservation procedure on the HHP-treated dermis specimen and CEA take on cryopreserved tissue., Methods: Nevus tissue harvested from a patient with GCMN was inactivated with HHP of 200 MPa and then cryopreserved at -30°C for 28 days. The cryopreserved specimen was compared with fresh (HHP-treated without cryopreservation) tissue and with untreated (without HHP treatment) tissue to evaluate the extracellular matrix, basal membranes, and capillaries. Cultured epidermis (CE) take on the cryopreserved tissue was evaluated following implantation of the cryopreserved nevus tissue with CE into the subcutis of nude mice., Results: No difference was observed between cryopreserved and fresh tissue in terms of collagen or elastic fibers, dermal capillaries, or basement membranes at the epidermal-dermal junction. In 4 of 6 samples (67%), applied CE took on the nevus tissues and regenerated the epidermis in the cryopreserved group compared with 5 of 6 samples (83%) in the fresh group., Conclusion: Cryopreservation at -30°C for 28 days did not result in significant damage to inactivated nevus tissue, and applied CE on the cryopreserved nevus tissues took and regenerated the epidermis. Inactivated nevus tissue with HHP can be used as a dermal substitute after 28-day cryopreservation., Competing Interests: The authors have no conflicts of interest to declare regarding the publication of this article, except for the collaborating research noted in the funding statement., (Copyright © 2021 Yoshitaka Matsuura et al.)

Early-stage gastrointestinal cancer is often treated by endoscopic submucosal dissection (ESD) using a flexible endoscope. Compared with conventional percutaneous surgery, ESD is much less invasive and provides a high quality of life for the patient because it does not require a skin incision, and the organ is preserved. However, the operator must be highly skilled because ESD requires using a flexible endoscope with energy devices, which have limited degrees of freedom. To facilitate easier manipulation of these flexible devices, we developed a surgical robot comprising a flexible endoscope and two articulating instruments. The robotic system is based on a conventional flexible endoscope, and an extrapolated motor unit moves the endoscope in all its degrees of freedom. The instruments are thin enough to allow insertion of two instruments into the endoscope channel, and each instrument has a bending section that allows for up-down, right-left, and forward-backward motion. In this study, we performed an ex vivo feasibility evaluation using the proposed robotic system for ESD in a porcine stomach. The procedure was successfully performed by five novice operators without complications. Our findings demonstrated the feasibility of the proposed robotic system and, furthermore, suggest that even operators with limited experience can use this system to perform ESD., Competing Interests: RN, TI, SOn, and MH have received research fund from Johnson & Johnson K.K., Japan. Employees of the company participated in the experiments. RN, TI, SOn, JA, SOg, TA, and MH have pending patent for the robot described in this paper., (Copyright © 2020 Ryu Nakadate et al.)

Adipose tissue regeneration in breast cancer patients without additional growth factors or adipose-tissue-derived stromal cells is desirable because of the possibility of recurrence and metastasis. We report that a poly-L-lactic acid (PLLA) mesh implant containing a collagen sponge (CS) maintained the internal space in vivo for up to 12 months and substituted for adipose tissue. We developed a PLLA capsule that maintained the internal space longer than that of PLLA mesh and compared adipose tissue formation at 12 and 24 months after implantation between the PLLA mesh with CS implant and the PLLA capsule implant with or without CS in a rabbit model. After 12 months, all implants maintained the internal space, and the adipose tissue that formed in all implant groups was larger than that in the control group. At 24 months, PLLA mesh maintained the internal space just as well as that at 12 months, while the PLLA capsule collapsed and accumulated a large number of macrophages. The formed adipose tissue in the PLLA mesh group was maintained up to 24 months; however, those in two PLLA capsule groups decreased and showed no difference from the control group. In conclusion, the internal space of the PLLA mesh implant with CS was substituted for adipose tissue at 12 months and sustained the formed adipose tissue after 24 months. The PLLA mesh implant containing CS is a desirable bioabsorbable implant that can be replaced by autologous adipose tissue after implantation in vivo without using any growth factors or cells., (© 2020 John Wiley & Sons, Ltd.)

Supplemental Digital Content is available in the text., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Purpose: The use of externalized jejunal monitoring flaps for jejunum transfers could be facilitative for the direct clinical assessment. Although this monitoring method would seem to be highly reliable, we modified this method and used mesentery only as a monitor to make it easy to manage the monitor more., Methods: Between 2013 and 2018, 43 patients underwent vascularized jejunum transfer for reconstruction of laryngopharyngectomy using the externalized mesentery monitor. There were 39 men and 4 women, and patient ages ranged from 40 to 80 years (average, 66.6 years). The nursing staff monitored the externalized mesentery by using handheld Doppler ultrasonography every 2 hours for 7 days after surgery., Results: Three patients had rather weak signal of handheld Doppler ultrasonography on the externalized mesentery monitors during operation, and handheld Doppler ultrasonography could not be applied. Of the remaining 40 patients using the externalized mesentery monitor with handheld Doppler ultrasonography, 39 had an uncomplicated postoperative period. In 1 patient, no signal of Doppler ultrasonography and lack of bleeding by pin prick from the monitor segment were noted in the immediate postoperative period, and revision of the vascular anastomosis was performed. Finally, the graft was salvaged. There was no case of infection in the monitoring flap or hypertrophic scar at the resected part of the flap., Conclusions: Using the externalized mesentery monitoring flaps, clinical monitoring by examining the exteriorized monitoring flap is possible, and only mesentery monitors were managed easily compared with jejunum monitoring flaps.

Background and Aims: Colonic endoscopic submucosal dissection (ESD) is time-consuming and bears a high risk of perforation. The aim of the present study was to compare the safety and efficacy between novel articulating devices and conventional ESD in live porcine colon models., Methods: Thirty ESDs in ten pigs were carried out at three different locations (15, 25, and 35 cm from the anus) by the conventional method (n = 15) and by the new method (n = 15). Procedure times, adverse events (perforation, bleeding), and damage to the muscular layer were recorded, and the ESD time per unit area of the specimens was calculated., Results: The perforation rate using the conventional method was 6.7% (1/15), whereas that using the new method was 0.0%. The number of sites of muscular damage was significantly lower in the new than conventional method (6 vs. 37, respectively; P = 0.024). The mean procedure time was significantly shorter in the new than conventional method (4.6 ± 2.0 vs. 7.0 ± 4.1 min/cm 2 , respectively; P = 0.042)., Conclusions: Use of the new ESD method allows for reduced adverse events and a shortened resection time.

Background: Difficulties in endoscopic operations and therapeutic procedures seem to occur due to the complexity of operating the endoscope dial as well as difficulty in performing synchronized movements with both hands. We developed a prototype robotic-assisted flexible endoscope that can be controlled with a single hand in order to simplify the operation of the endoscope. The aim of this study was to confirm the operability of the robotic-assisted flexible endoscope (RAFE) by performing endoscopic submucosal dissection (ESD)., Methods: Study 1: ESD was performed manually or with RAFE by an expert endoscopist in ex vivo porcine stomachs; six operations manually and six were performed with RAFE. The procedure time per unit circumferential length/area was calculated, and the results were statistically analyzed. Study 2: We evaluated how smoothly a non-endoscopist can move a RAFE compared to a manual endoscope by assessing the designated movement of the endoscope., Results: Study 1: En bloc resection was achieved by ESD using the RAFE. The procedure time was gradually shortened with increasing experience, and the procedure time of ESD performed with the RAFE was not significantly different from that of ESD performed with a manual endoscope. Study 2: The time for the designated movement of the endoscope was significantly shorter with a RAFE than that with a manual endoscope as for a non-endoscopist., Conclusions: The RAFE that we developed enabled an expert endoscopist to perform the ESD procedure without any problems and allowed a non-endoscopist to control the endoscope more easily and quickly than a manual endoscope. The RAFE is expected to undergo further development.

Purpose: Image guidance is a key technology that can improve the outcome of laparoscopic surgery. However, due to the large deformation caused by digestive organs, a computer-aided navigation system based on preoperative imaging data cannot indicate the correct target position of the lesion (e.g., liver tumors and vessels invisible from the organ surface). To overcome this issue, we developed a laparoscopic ultrasound manipulator with two motorized degrees of freedom at the tip, allowing for the performance of a dexterous ultrasound scan in a confined laparoscopic surgical area., Method: The developed manipulator consists of a compact and elastic structure using springs, enabling a safe ultrasound scan and avoiding excess force on the inspected organs. The manipulator is a handheld device equipped with four buttons at the handle, which the surgeon directly grasps to send a motion command to the tip structure. The developed prototype realizes two motorized degree-of-freedom motion at the tip. The size of prototype is 15.0 mm in diameter that is usable in conventional laparoscopy. The tip of the manipulator was carefully designed by considering the kinematic model and the results of the finite element analysis., Results: To assess the prototype, accuracy and rigidity were measured by using a motion processing microscope. The accuracy test showed that the proposed device has a fairly accurate characteristic as a handheld device. This was supposedly caused by the nature of compliant mechanism, which does not have mechanical play in motion. In addition, the intrinsic elastic structure (approximately 2.0 N/mm in most of the range of motion) allowed the ultrasound probe to adequately fit on the curved organ surface without extra effort of manipulation during the inspection. In the in vivo experiment, the yaw motion was found to be effective for investigating the vascular network because the manipulator allows the probe to be rotated while maintaining the same position., Conclusion: The mechanical evaluation and in vivo test results showed high feasibility of the prototype. We are currently working on further mechanical improvement for commercialization and development of a real-time navigation system that can perform three-dimensional reconstruction of ultrasonographic images by implementing a magnetic position sensor at the tip of the manipulator.

Robotic prostheses are expected to allow amputees greater freedom and mobility. However, available options to control transhumeral prostheses are reduced with increasing amputation level. In addition, for electromyography-based control of prostheses, the residual muscles alone cannot generate sufficiently different signals for accurate distal arm function. Thus, controlling a multi-degree of freedom (DoF) transhumeral prosthesis is challenging with currently available techniques. In this paper, an electroencephalogram (EEG)-based hierarchical two-stage approach is proposed to achieve multi-DoF control of a transhumeral prosthesis. In the proposed method, the motion intention for arm reaching or hand lifting is identified using classifiers trained with motion-related EEG features. For this purpose, neural network and k -nearest neighbor classifiers are used. Then, elbow motion and hand endpoint motion is estimated using a different set of neural-network-based classifiers, which are trained with motion information recorded using healthy subjects. The predictions from the classifiers are compared with residual limb motion to generate a final prediction of motion intention. This can then be used to realize multi-DoF control of a prosthesis. The experimental results show the feasibility of the proposed method for multi-DoF control of a transhumeral prosthesis. This proof of concept study was performed with healthy subjects., Competing Interests: The authors declare no conflict of interest.

Background and Objective: Little is known about the approximation of coapted edges in sutureless laser-assisted vessel welding. Tissue shrinkage by laser irradiation may cause coapted edges to separate, reducing strength of welding. This may be avoided by preloaded longitudinal compression on the tissue edges to be welded. This study compared welding strength with and without preloaded compression in ex vivo animal experiments., Materials and Methods: This study evaluated 24 samples of harvested porcine carotid arteries, each having a length of 3 cm and an inner diameter of 1.0-2.0 mm. A half circumferential incision was made at the center of each sample. A steel shaft 2.0 mm in diameter was inserted into each sample to approximate the incised edges. The samples were longitudinally compressed to 6 mm. Incision sites were repaired by irradiation with a 970-nm diode laser. No glue or die was used. The repair strength was evaluated by measuring the bursting point (BP) of all samples. In a pilot study, the welding conditions, including power, duration, and interval of the laser spots, were tested by trial and error in 18 samples, including six treated under optimum conditions. As a control group, six samples were welded under optimum conditions, but without compression., Results: Optimum conditions, consisting of 2.4 W power, 30-second duration, and 1-mm intervals of laser spots, yielded the highest BP (623 ± 236 mmHg), which was significantly higher than in the control group without compression (204 ± 208 mmHg, P = 0.009). Defining BP > 400 mmHg as successful repair, the success rates in the compression and control groups were 83% and 17%, respectively., Conclusion: Preloaded longitudinal compression on the coapted edges may be important for sutureless laser-assisted vessel repair and anastomosis and may affect the strength of welding. Lasers Surg. Med. 49:533-538, 2017. © 2017 Wiley Periodicals, Inc., (© 2017 Wiley Periodicals, Inc.)

There is a demand for a new neurorehabilitation modality with a brain-computer interface for stroke patients with insufficient or no remaining hand motor function. We previously developed a robotic hand rehabilitation system triggered by multichannel near-infrared spectroscopy (NIRS) to address this demand. In a preliminary prototype system, a robotic hand orthosis, providing one degree-of-freedom motion for a hand's closing and opening, is triggered by a wireless command from a NIRS system, capturing a subject's motor cortex activation. To examine the feasibility of the prototype, we conducted a preliminary test involving six neurologically intact participants. The test comprised a series of evaluations for two aspects of neurorehabilitation training in a real-time manner: classification accuracy and execution time. The effects of classification-related factors, namely the algorithm, signal type, and number of NIRS channels, were investigated. In the comparison of algorithms, linear discrimination analysis performed better than the support vector machine in terms of both accuracy and training time. The oxyhemoglobin versus deoxyhemoglobin comparison revealed that the two concentrations almost equally contribute to the hand motion estimation. The relationship between the number of NIRS channels and accuracy indicated that a certain number of channels are needed and suggested a need for a method of selecting informative channels. The computation time of 5.84 ms was acceptable for our purpose. Overall, the preliminary prototype showed sufficient feasibility for further development and clinical testing with stroke patients.

Purpose: In minimally invasive surgery, instruments are inserted from the exterior of the patient's body into the surgical field inside the body through the minimum incision, resulting in limited visibility, accessibility, and dexterity. To address this problem, surgical instruments with articulated joints and multiple degrees of freedom have been developed. The articulations in currently available surgical instruments use mainly wire or link mechanisms. These mechanisms are generally robust and reliable, but the miniaturization of the mechanical parts required often results in problems with size, weight, durability, mechanical play, sterilization, and assembly costs., Methods: We thus introduced a compliant mechanism to a laparoscopic surgical instrument with multiple degrees of freedom at the tip. To show the feasibility of the concept, we developed a prototype with two degrees of freedom articulated surgical instruments that can perform the grasping and bending movements. The developed prototype is roughly the same size of the conventional laparoscopic instrument, within the diameter of 4 mm. The elastic parts were fabricated by Ni-Ti alloy and SK-85M, rigid parts ware fabricated by stainless steel, covered by 3D- printed ABS resin. The prototype was designed using iterative finite element method analysis, and has a minimal number of mechanical parts., Results: The prototype showed hysteresis in grasping movement presumably due to the friction; however, the prototype showed promising mechanical characteristics and was fully functional in two degrees of freedom. In addition, the prototype was capable to exert over 15 N grasping that is sufficient for the general laparoscopic procedure. The evaluation tests thus positively showed the concept of the proposed mechanism., Conclusion: The prototype showed promising characteristics in the given mechanical evaluation experiments. Use of a compliant mechanism such as in our prototype may contribute to the advancement of surgical instruments in terms of simplicity, size, weight, dexterity, and affordability.

Background and Study Aims: The conventional procedure of endoscopic submucosal dissection (ESD) is technically demanding. This study investigated the efficiency of novel articulating devices (maximum diameter 2.6 mm), which can be used with commercially available, standard endoscopes., Patients and Methods: In an ex vivo comparative study, eight endoscopists were divided into novices and experienced operators, and performed ESD using new devices and the conventional setup. An in vivo animal experiment was performed by two experts. Procedure times for incision and dissection were recorded, and unit times for circumferential length and area of specimens were calculated., Results: All procedures were successfully completed with en bloc resection. In the ex vivo study, the unit procedure times for incision and dissection by novices were significantly shorter using the new system (P < 0.01 and P < 0.05), whereas there was no significant difference for experienced endoscopists. Perforation occurred during one procedure in which the new system was used. The in vivo experiments were successfully completed without adverse events., Conclusions: ESD using novel articulating devices was feasible. These devices were able to reduce the procedure time for novices., (© Georg Thieme Verlag KG Stuttgart · New York.)

At present, much of the research conducted worldwide focuses on extending the ability of surgical robots. One approach is to extend robotic dexterity. For instance, accessibility and dexterity of the surgical instruments remains the largest issue for reduced port surgery such as single port surgery or natural orifice surgery. To solve this problem, a great deal of research is currently conducted in the field of robotics. Enhancing the surgeon's perception is an approach that uses advanced sensor technology. The real-time data acquired through the robotic system combined with the data stored in the robot (such as the robot's location) provide a major advantage. This paper aims at introducing state-of-the-art products and pre-market products in this technological advancement, namely the robotic challenge in extending dexterity and hopefully providing the path to robotic surgery in the near future.

The rubber hand illusion is a well-known multisensory illusion. In brief, watching a rubber hand being stroked by a paintbrush while one's own unseen hand is synchronously stroked causes the rubber hand to be attributed to one's own body and to "feel like it's my hand." The rubber hand illusion is thought to be triggered by the synchronized tactile stimulation of both the subject's hand and the fake hand. To extend the conventional rubber hand illusion, we introduce robotic technology in the form of a master-slave telemanipulator. The developed one degree-of-freedom master-slave system consists of an exoskeleton master equipped with an optical encoder that is worn on the subject's index finger and a motor-actuated index finger on the rubber hand, which allows the subject to perform unilateral telemanipulation. The moving rubber hand illusion has been studied by several researchers in the past with mechanically connected rigs between the subject's body and the fake limb. The robotic instruments let us investigate the moving rubber hand illusion with less constraints, thus behaving closer to the classic rubber hand illusion. In addition, the temporal delay between the body and the fake limb can be precisely manipulated. The experimental results revealed that the robotic instruments significantly enhance the rubber hand illusion. The time delay is significantly correlated with the effect of the multisensory illusion, and the effect significantly decreased at time delays over 100 ms. These findings can potentially contribute to the investigations of neural mechanisms in the field of neuroscience and of master-slave systems in the field of robotics.

Purpose: We are currently developing a neurosurgical robotic system that facilitates access to residual tumors and improves brain tumor removal surgical outcomes. The system combines conventional and robotic surgery allowing for a quick conversion between the procedures. This concept requires a new master console that can be positioned at the surgical bedside and be sterilized., Methods: The master console was developed using new technologies, such as a parallel mechanism and pneumatic sensors. The parallel mechanism is a purely passive 5-DOF (degrees of freedom) joystick based on the author's haptic research. The parallel mechanism enables motion input of conventional brain tumor removal surgery with a compact, intuitive interface that can be used in a conventional surgical environment. In addition, the pneumatic sensors implemented on the mechanism provide an intuitive interface and electrically isolate the tool parts from the mechanism so they can be easily sterilized., Results: The 5-DOF parallel mechanism is compact (17 cm width, 19cm depth, and 15cm height), provides a 505,050 mm and 90° workspace and is highly backdrivable (0.27N of resistance force representing the surgical motion). The evaluation tests revealed that the pneumatic sensors can properly measure the suction strength, grasping force, and hand contact. In addition, an installability test showed that the master console can be used in a conventional surgical environment., Conclusion: The proposed master console design was shown to be feasible for operative neurosurgery based on comprehensive testing. This master console is currently being tested for master-slave control with a surgical robotic system.

Gradual lengthening by distraction osteogenesis is widely used for brachydactyly. The most frequent postoperative complaint of the patients treated with this method is the appearance of the scar caused by the skin incision for the osteotomy, which is an integral technique of distraction osteogenesis. A nonincisional approach to osteotomy would reduce the dorsal scarring. Gradual lengthening by callus distraction with nonincisional osteotomy was performed in 14 digits. The mean gain in length was 14.3 mm (10-19 mm). Of 14 digits, 13 digits achieved the target length and sufficient bone consolidation and 1 digit showed early consolidation. There was no case in which complications occurred because of the drilling. Nonincisional osteotomy for callus distraction in the hand and foot reduced dorsal longitudinal scarring and achieved good cosmetic results as compared with an ordinary osteotomy involving skin incision.

The Japanese Dermatological Association established an advisory committee in 1995 to develop a severity scoring system for atopic dermatitis (AD). Its interim and concluding reports were published in Japanese in the Japanese Journal of Dermatology (108: 1491-1496, 1998 and 111: 2023-2033, 2001). Because of the strong demand for an English version, we have decided to publish the reports in English. This manuscript is the English version of the concluding report. The interim report suggested that eruption components such as erythema, papule, erosion, crust, excoriation and lichenification with extent of involved areas in five body regions, including the head and neck, anterior and posterior trunks, and upper and lower limbs, were important items for assessing AD severity. Additionally, it was recommended that streamlining of eruption components was mandatory for improving the statistical validity and reliability. The committee members subsequently concentrated their efforts on this task, and finally proposed an Atopic Dermatitis Severity Classification Criteria of the Japanese Dermatological Association., (© 2011 Japanese Dermatological Association.)

The Japanese Dermatological Association established an advisory committee in 1995 to set up severity scoring systems for atopic dermatitis (AD). Its interim report was published in Japanese in the Japanese Journal of Dermatology (108: 1491-1496, 1998) by Chairman Hikotaro Yoshida. Because of the strong demand for an English version, we have decided to publish the report in English. This prospective study was designed to evaluate the status of 259 AD patients using Method 1, which involves a simple global evaluation of disease severity; Method 2, which involves global evaluation by summing severity scores obtained from five body regions (i.e. the head and neck, anterior and posterior trunks, and upper and lower limbs); Method 3, which consists of both assessment of the extent of involved areas at each of the five body regions and that of the severity scores of each eruption component observed in the most severely affected body region; and Method 4, which consists of the evaluation of only subjective components (daytime pruritus and sleep disturbance). Employing the results obtained with Method 1 as a tentative benchmark, we analyzed its correlation with those of Methods 2, 3 and 4 to statistically assess the validity and reliability of these methods. Method 2, Method 3 and the portion of Method 4 involving evaluation of only the subjective symptom of daytime pruritus but not the sleep disturbance were considered useful in evaluating AD severity., (© 2011 Japanese Dermatological Association.)

Purpose: Brain tumor (e.g., glioma) resection surgery, representing the first step for many treatments, is often difficult and time-consuming for neurosurgeons. Thus, intelligent neurosurgical instruments have been developed to improve tumor removal., Methods: The concept and robotic structure of intelligent neurosurgical instruments were introduced. These instruments consist of a surgical robot, a master device and operating software. The robot incorporates a surgical motion base and tool manipulator, including a volume control suction tool. Open Core Control software was developed for connecting intelligent neurosurgical instruments through a network connection and integrating the instruments into a system., Results: Mechanical evaluation tests on the components and a preliminary system evaluation were performed. A phantom model was fixed on a head frame, and a tumor-removal procedure was successfully performed using prototype intelligent neurosurgical instruments., Conclusion: Intelligent neurosurgical instruments are feasible and suitable for on-going evaluation in practical tasks, including in-vivo animal testing.

Object: In these days, patients and doctors in operation room are surrounded by many medical devices as resulting from recent advancement of medical technology. However, these cutting-edge medical devices are working independently and not collaborating with each other, even though the collaborations between these devices such as navigation systems and medical imaging devices are becoming very important for accomplishing complex surgical tasks (such as a tumor removal procedure while checking the tumor location in neurosurgery). On the other hand, several surgical robots have been commercialized, and are becoming common. However, these surgical robots are not open for collaborations with external medical devices in these days. A cutting-edge "intelligent surgical robot" will be possible in collaborating with surgical robots, various kinds of sensors, navigation system and so on. On the other hand, most of the academic software developments for surgical robots are "home-made" in their research institutions and not open to the public. Therefore, open source control software for surgical robots can be beneficial in this field. From these perspectives, we developed Open Core Control software for surgical robots to overcome these challenges., Materials and Methods: In general, control softwares have hardware dependencies based on actuators, sensors and various kinds of internal devices. Therefore, these control softwares cannot be used on different types of robots without modifications. However, the structure of the Open Core Control software can be reused for various types of robots by abstracting hardware dependent parts. In addition, network connectivity is crucial for collaboration between advanced medical devices. The OpenIGTLink is adopted in Interface class which plays a role to communicate with external medical devices. At the same time, it is essential to maintain the stable operation within the asynchronous data transactions through network. In the Open Core Control software, several techniques for this purpose were introduced. Virtual fixture is well known technique as a "force guide" for supporting operators to perform precise manipulation by using a master-slave robot. The virtual fixture for precise and safety surgery was implemented on the system to demonstrate an idea of high-level collaboration between a surgical robot and a navigation system. The extension of virtual fixture is not a part of the Open Core Control system, however, the function such as virtual fixture cannot be realized without a tight collaboration between cutting-edge medical devices. By using the virtual fixture, operators can pre-define an accessible area on the navigation system, and the area information can be transferred to the robot. In this manner, the surgical console generates the reflection force when the operator tries to get out from the pre-defined accessible area during surgery., Results: The Open Core Control software was implemented on a surgical master-slave robot and stable operation was observed in a motion test. The tip of the surgical robot was displayed on a navigation system by connecting the surgical robot with a 3D position sensor through the OpenIGTLink. The accessible area was pre-defined before the operation, and the virtual fixture was displayed as a "force guide" on the surgical console. In addition, the system showed stable performance in a duration test with network disturbance., Conclusion: In this paper, a design of the Open Core Control software for surgical robots and the implementation of virtual fixture were described. The Open Core Control software was implemented on a surgical robot system and showed stable performance in high-level collaboration works. The Open Core Control software is developed to be a widely used platform of surgical robots. Safety issues are essential for control software of these complex medical devices. It is important to follow the global specifications such as a FDA requirement "General Principles of Software Validation" or IEC62304. For following these regulations, it is important to develop a self-test environment. Therefore, a test environment is now under development to test various interference in operation room such as a noise of electric knife by considering safety and test environment regulations such as ISO13849 and IEC60508. The Open Core Control software is currently being developed software in open-source manner and available on the Internet. A communization of software interface is becoming a major trend in this field. Based on this perspective, the Open Core Control software can be expected to bring contributions in this field.

Background: With increasing research on system integration for image-guided therapy (IGT), there has been a strong demand for standardized communication among devices and software to share data such as target positions, images and device status., Method: We propose a new, open, simple and extensible network communication protocol for IGT, named OpenIGTLink, to transfer transform, image and status messages. We conducted performance tests and use-case evaluations in five clinical and engineering scenarios., Results: The protocol was able to transfer position data with submillisecond latency up to 1024 fps and images with latency of <10 ms at 32 fps. The use-case tests demonstrated that the protocol is feasible for integrating devices and software., Conclusion: The protocol proved capable of handling data required in the IGT setting with sufficient time resolution and latency. The protocol not only improves the interoperability of devices and software but also promotes transitions of research prototypes to clinical applications., (Copyright (c) 2009 John Wiley & Sons, Ltd.)

Authors evaluated the impact of computerized alerts on the quality of outpatient laboratory monitoring for transplant patients. For 356 outpatient liver transplant patients managed at LDS Hospital, Salt Lake City, this observational study compared traditional laboratory result reporting, using faxes and printouts, to computerized alerts implemented in 2004. Study alerts within the electronic health record notified clinicians of new results and overdue new orders for creatinine tests and immunosuppression drug levels. After implementing alerts, completeness of reporting increased from 66 to >99 %, as did positive predictive value that a report included new information (from 46 to >99 %). Timeliness of reporting and clinicians' responses improved after implementing alerts (p <0.001): median times for clinicians to receive and complete actions decreased to 9 hours from 33 hours using the prior traditional reporting system. Computerized alerts led to more efficient, complete, and timely management of laboratory information.

Epidermal keratinocytes contain 15-lipoxygenase, which generates 15-hydroxyeicosatetraenoic acid, a major metabolite of arachidonic acid. Although two isozymes, 15-lipoxygenase-1 and -2, exist, it remains unclear which isozyme plays an important role in inflammatory processes and proliferative skin diseases. In the present study, we demonstrated that 15-lipoxygenase-2 expression was increased in normal human epidermal keratinocytes and HaCaT cells treated with interferon-gamma (200 U/ml), while no induction of 15-lipoxygenase-1 was observed. Under the same culture conditions, no 15-lipoxygenase-2 was expressed by a carcinoma cell line, A431. Weak expression of 15-lipoxygenase-2 was observed in the basal cell layer of non-lesional psoriatic skin by in situ hybridization and immunostaining, whereas strong expression of 15-lipoxygenase-2 was observed in all living layers of psoriatic lesions. Actinic keratosis and squamous cell carcinomas showed a variable immunostaining pattern for 15-lipoxygenase-2. These results indicate that 15-lipoxygenase-2 is implicated in interferon-gamma-induced inflammatory processes in normal human epidermal keratinocytes and psoriatic skin.

We describe a girl with cutaneous angiolipoleiomyoma on the buttock. The 16-year-old girl had a 2.5- x 1.5-cm subcutaneous tumor on the right buttock, which was slightly tender. The tumor appeared to be vascular and was, therefore, surgically excised. Histologically, the lesion was poorly circumscribed and was composed of differently sized blood vessels, smooth-muscle bundles, and mature adipose tissue. These histologic findings were consistent with those of angiomyolipoma, which commonly occurs in the kidney. Cutaneous angiomyolipoma, which is also known as cutaneous angiolipoleiomyoma, is a rare benign mesenchymal tumor. To our knowledge, only 16 cases have been reported in the English-language literature. In our report, we review the clinical features of 17 cases, including the current one. We point out the differences between the cutaneous and renal forms of angiomyolipoma, and conclude that the cutaneous lesion is distinct from a renal lesion in several aspects, including tuberous sclerosis complex association and immunoreactivity to both HMB-45 and MART-1.

Object: To enhance the surgeon's dexterity and maneuverability in the deep surgical field, the authors developed a master-slave microsurgical robotic system. This concept and the results of preliminary experiments are reported in this paper., Methods: The system has a master control unit, which conveys motion commands in six degrees of freedom (X, Y, and Z directions; rotation; tip flexion; and grasping) to two arms. The slave manipulator has a hanging base with an additional six degrees of freedom; it holds a motorized operating unit with two manipulators (5 mm in diameter, 18 cm in length). The accuracy of the prototype in both shallow and deep surgical fields was compared with routine freehand microsurgery. Closure of a partial arteriotomy and complete end-to-end anastomosis of the carotid artery (CA) in the deep operative field were performed in 20 Wistar rats. Three routine surgical procedures were also performed in cadavers. The accuracy of pointing with the nondominant hand in the deep surgical field was significantly improved through the use of robotics. The authors successfully closed the partial arteriotomy and completely anastomosed the rat CAs in the deep surgical field. The time needed for stitching was significantly shortened over the course of the first 10 rat experiments. The robotic instruments also moved satisfactorily in cadavers, but the manipulators still need to be smaller to fit into the narrow intracranial space., Conclusions: Computer-controlled surgical manipulation will be an important tool for neurosurgery, and preliminary experiments involving this robotic system demonstrate its promising maneuverability.

Background: Panton-Valentine leukocidin (PVL) is mainly associated with necrotic suppurative lesions, such as furuncles and abscesses in the skin and subcutaneous tissue, but it has also been isolated from patients with community-acquired, severe, necrotizing pneumonia. However, the clinical manifestations of furuncles caused by PVL-producing Staphylococcus aureus and the role of patients' background are not fully understood., Methods: We used polymerase chain reaction amplification to test for the PVL gene in 161 strains of S. aureus isolated from suppurative skin lesions. For all PVL gene-positive strains isolated from furuncles, we analyzed cutaneous manifestations, patient background characteristics, and bacteriological markers, including coagulase types, presence of the mecA gene, and toxin profiles, and we compared these results with those for PVL gene-negative strains., Results: PVL genes were detected in 16 (40%) of the 40 S. aureus strains isolated from furuncles, 2 (28%) of the 7 strains isolated from carbuncles, 1 (14%) of the 7 strains isolated from abscesses, and 1 (5%) of the 20 strains isolated from folliculitis. PVL gene-positive S. aureus usually causes multiple (rather than single) furuncles, and such furuncles are usually associated with more-intense erythema around the lesions. PVL gene-positive strains were isolated from young adults without underlying diseases, whereas PVL gene-negative strains were isolated from patients with various systemic complications, including diabetes, leukemia, and autoimmune diseases., Conclusions: PVL gene-positive S. aureus strains are involved in the development of multiple furuncles with more-intense erythema, particularly in healthy young adults. An understanding of the characteristics of furuncles due to PVL gene-positive strains might be useful for preventing the development of the severe systemic infections.

To clarify the effect of formaldehyde (FA) gas exposure on contact hypersensitivity (CHS), CHS reactions against 2,4,6-trinitrochlorobenzene (TNCB) was studied in BALB/c mice with a low dose of FA gas exposure. The TNCB-induced CHS reactions were slightly suppressed by the FA gas exposure immediately after sensitization, whereas they were significantly enhanced and prolonged in mice continuously exposed to FA gas before and after sensitization. We showed that exposure to FA gas enhanced the Th2 dominant responses in draining lymph node (LN) in early stage of CHS. In contrast, T cell subsets and their intracellular cytokine production in the draining LN were similar during the early stage of CHS by FA gas exposure during the sensitization phase. The percentage of CD8+ T cells was increased, and the percentage of CD4+CD25+ T cells was decreased in the FA gas-exposed group at 72 hr after elicitation. These results indicate that FA gas-exposed might influence regulatory T cells. Furthermore, in the chronic CHS model that was repetitively elicited with TNCB, more intensive and prolonged CHS reactions, and increased numbers of mast cells were found in the FA gas-exposed group at 4 hr after elicitation than in the control group, FA gas exposure may alter the intensity of allergic CHS.

Double-stranded RNA-activated protein kinase (PKR) is a interferon-induced protein initially known for its inhibitory effects on cellular and viral protein synthesis. In recent studies, PKR has been shown to be an important participant in a broad array of cellular processes, including signal transduction, differentiation, apoptosis, cell growth, and tumorigenesis. The expression of PKR in normal human keratinocytes (NHEK) was examined, and its expression in several skin lesions was compared immunohistochemically with that of proliferating cell nuclear antigen (PCNA). Expression of PKR mRNA was detected in NHEK without IFNgamma treatment; the level of PKR mRNA increased with IFNgamma treatment for two hours. Immunoblot analysis revealed that the monoclonal anti-PKR antibody reacted specifically with a 68kDa PKR protein in extracts from NHEK. Immunohistochemistry revealed that PKR protein was expressed in normal epidermis and mucosa. PKR expression was not restricted only to suprabasal cells but was also observed in basal cells positive for PCNA. In psoriatic plaques, PKR expression was lower in basal and parabasal keratinocytes and comparable in suprabasal keratinocytes to the levels in normal skin. PKR was partially detected in atypical cells in non-invasive keratinocytic neoplasia but was completely absent from undifferentiated tumor cells of squamous cell carcinoma. The present study demonstrated that PKR protein is constitutively expressed in epidermal and epithelial keratinocytes of normal skin and mucosa and indicated that a loss of PKR is not associated with the malignant transformation itself but with the increased cell proliferative activity and the altered differentiation of keratinocytes.

Two cases of multi-level fingertip amputation are presented. In each case, replantation was achieved in a two-stage procedure, involving reattachment, de-epithelialisation and insertion into a palmar pocket in stage 1, followed by removal from the palmar pocket 16 days later. The cases are described and the technique is discussed.

There are several fixation techniques for osteosynthesis in digital replantation. Kirschner wire fixation is used commonly but the wires protrude and disturb mobilization. Moreover, it requires removal. Since February 1995, the authors have been using a bioabsorbable rod made of poly-L-lactide as an intramedullary nail for osteosynthesis in digital replantation. The advantages of this technique include the absence of protruding hardware that would require removal and technical simplicity. This method has been applied for 15 arthrodeses (12 distal interphalangeal joints, 1 proximal interphalangeal joint, and 2 interphalangeal joints of the thumb) and for 11 diaphysis fractures (5 proximal, 5 middle, and 1 distal phalanx). All patients were observed until there was clinical and radiographic evidence of fusion (average interval to fusion, 8.4 wk). Bone resorption occurred in one patient. There were no cases of nonunion or infection. Poly-L-lactide rod fixation is a simple and effective technique.