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Intraoperative or early postoperative vascular complications are not uncommon problems in sagittal split osteotomies of the mandibular ramus; however, reports of late complications are considerably rarer. Here, we present two patients who sustained late vascular complications after the sagittal split osteotomy. The first patient had a delayed bleeding, which presented itself as a rapidly expanding swelling of the left cheek from the left external carotid artery 18 days postoperatively. During exploration, a 2 mm laceration of the external carotid artery located just proximal to the bifurcation of the internal maxillary artery and the superficial temporal artery was successfully repaired. The prominent bony spike of the cut end of medial cortex of the set-back mandibular ramus was found against the arterial wall and could possibly have caused the progressive necrosis of the wall with subsequent spontaneous rupture. The second patient suffered from a mild noise in the right ear 2 weeks after the initial surgery; however, a pre-auricular arteriovenous fistula between the right external carotid artery and the external jugular vein was discovered 1 year postoperatively. The diagnosis was confirmed by angiography, and the lesion was treated successfully by therapeutic embolization at that time. To avoid vascular injury, sufficient protection of the soft tissue during exposure of the mandibular ramus is mandatory. In addition, the direction of the cut of medial cortex is suggested to avoid the cranialward inclination that creates a sharp, bony end against the artery. Awareness of the possible late vascular complications to facilitate early detection and management is also important.

The visual outcome of 39 patients who had unilateral indirect type traumatic optic neuropathy and periorbital facial bone fracture treated at the Chang Gung Memorial Hospital in Kaohsiung between June 1996 and June 2001 was retrospectively evaluated, based on the results of computed tomography studies that grouped the associated fractures as anterior orbital fracture, posterior orbital fracture, orbital blow-in or blow-out fracture. Pretreatment and posttreatment visual acuities were obtained from the medical records and measurements of visual improvement degree and percentage were calculated after converting the visual acuities into log of the minimum angle of resolution (log MAR) units. This study reveals that posterior orbital fracture is associated with a worse prognosis in visual outcome than anterior orbital fracture, with visual improvement degree and percentage being 0.86 ± 0.17 log MAR and 34.2 ± 1.7% versus 1.56 ± 0.27 log MAR and 58.9 ± 1.7%, respectively (P = 0.02 and 0.004). Blow-in fractures such as an impacted lateral orbital wall did not predict significant deterioration in visual outcome. In addition, orbital floor or medial wall blow-out fractures did not predict significant improvement in visual outcome.

To repair a 10 x 16 cm soft tissue defect of right lower leg that accompanied with occluded anterior and posterior tibial arteries in a 30-year-old man who sustained comminuted type III(B) Gustilo open tibial and fibular fracture, we present a successful reconstruction by using a large distally based sural island flap perfused by the lowermost perforator of the peroneal artery. This flap is a useful alternative for distal extremity reconstruction when anterior and posterior tibial arteries are occluded, as large flaps can be elevated safely based on only one peroneal perforator.

To assess the feasibility of remote management of extremity wound by using a mobile camera phone to transfer clinical images and online communication, teleconsultations were carried out on 60 patients between January and August 2003 for 82 extremity wounds presented to the emergency room between residents and consultant plastic surgeons. A questionnaire about wound descriptors (gangrene, necrosis, erythema, and cellulitis/infection), as well as clinical opinions regarding treatment with antibiotics or debridement, was filled out. In this study, 3 surgeons were able to make 80%, 76%, 66%, and 74% agreement, respectively, in the remote diagnosis regarding presence of gangrene, necrosis, erythema, and cellulitis/infection. Recognition of gangrene had the highest agreement percent (80%), sensitivity (85%), and specificity (93%). There were 68% to 90% of image sets that could be made with equivalent diagnoses of wound descriptors and 83% of wounds managed as per the remote treatment recommendation regarding whether to use antibiotics or to perform debridement. The preliminary results showed that the camera phone is valuable and bears potential for remote management of the extremity wound.

We describe the case of a female with end-stage renal disease who developed a left ischemic hand and index finger gangrene 2 years after commencement of hemodialysis. Ray amputation was performed, however, the surgical wound was complicated by progressive soft tissue necrosis and metacarpal bones exposure. To avoid amputation at a higher level, we repaired the defect successfully with a free anterolateral thigh perforator flap. A radiocephalic arteriovenous fistula, the dialysis access, was divided to provide the recipient vessels. Reconstruction with this method has the advantage of a staged arteriovenous fistula, which can increase the free-flap success rate, and has the potential to improve perfusion of the distal ischemic hand.

This study evaluated the outcome for 45 consecutive, nonrandomized patients whose indirect type traumatic optic neuropathy and periorbital facial bone fracture were treated at the Chang Gung Memorial Hospital in Kaohsiung between June of 1996 and June of 2001. There were a total of 48 eye injuries in 45 patients (3 patients sustained bilateral eye injuries). Data related to megadose steroid treatment, timing of open reduction and internal fixation for periorbital facial fractures, and pretreatment and post-treatment of visual acuities were collected from the medical records. Measurements of visual improvement in terms of degree and percentage were calculated after the visual acuities were converted into the log of the minimum angle of resolution units. Visual acuities were significantly improved according to mechanism of injury, gender, or associated periorbital skin laceration wound. However, no light perception for eight patients at initial presentation and gradually deteriorating vision in four injured eyes of three patients were identified as poor prognostic factors. Therefore, repeated visual measurements are recommended to detect any gradually deteriorating vision, which although uncommon, has a poor prognosis. No significantly improved vision was found after treatment with megadose steroids. However, if improvement in vision did occur, treatment with megadose steroids resulted in a much greater visual improvement in terms of degree (p = 0.001) and percentage (p = 0.02). Thus treatment with megadose steroid is recommended. No significant differences were found in the visual improvement between those who received and those who did not receive periorbital open reduction and internal fixation operations, and between those who received early repair within 48 hours and those who received late repair after more than 48 hours. However, it seems medicolegally prudent to delay the procedure because some patients may experience gradually deteriorating vision, which has a poor prognosis, and because postoperative visual loss after facial fracture repair did happen.

The anterolateral thigh adipofascial flap is a vascularized flap prepared from the adipofascial layer of the anterolateral thigh region. It is a perforator flap based on septocutaneous or musculocutaneous perforators of the lateral circumflex femoral system. With methods similar to those used for the free anterolateral thigh flap, only the deep fascia of the anterolateral thigh and a 2-mm-thick to 3-mm-thick layer of subcutaneous fatty tissue above the fascia were harvested. In 11 cases, this flap (length, 5 to 11 cm; width, 4 to 8 cm) was used for successful reconstruction of extremity defects. Split-thickness skin grafts were used to immediately resurface the adipofascial flaps for eight patients, and delayed skin grafting was performed for the other three patients. The advantage of the anterolateral thigh adipofascial flap is its ability to provide vascularized, thin, pliable, gliding coverage. In addition, the donor-site defect can be closed directly. Other advantages of this flap, such as safe elevation, a long wide vascular pedicle, a large flap territory, and flow-through properties that allow simultaneous reconstruction of major-vessel and soft-tissue defects, are the same as for the conventional anterolateral thigh flap. The main disadvantage of this procedure is the need for a skin graft, with the possible complications of subsequent skin graft loss or hyperpigmentation.

The Osteoporosis Self-assessment Tool for Asians (OSTA) is a validated index based on age and weight to predict the risk of osteoporosis in women. This cross-sectional study was designed to evaluate the impact of sexual dimorphism on the trauma patterns and the clinical outcomes of patients with high-risk OSTA scores. Trauma data of patients with high-risk OSTA scores between 1 January 2009 and 31 December 2015 were retrieved from the trauma registry system of a level I trauma center. A total of 2248 patients including 1585 women and 663 men were included in this study. In-hospital mortality was assessed as the primary outcome in the propensity score-matched analyses of the female and male patients, which were created in a 1:1 ratio under the adjustment of potential confounders, including age, co-morbidity, mechanism and injury-severity score (ISS). Female patients with a high-risk OSTA score had significantly lower mortality rates than their male counterparts. Among the propensity score-matched population, female patients had lower odds of having cerebral contusion and pneumothorax, but higher odds of presenting with radial, ulnar and femoral fractures than male patients. In addition, the female patients still had significantly lower odds of mortality (odds ratio (OR), 0.5; 95% confidence interval (CI), 0.29–0.90; p = 0.019) than the male patients. However, no significant differences were noted in the length of stay (LOS) in hospital, intensive-care unit (ICU) admission, and LOS in the ICU between the sexes. Female patients with high-risk OSTA scores showed different injury patterns and significantly lower mortality rates than their male counterparts, even after controlling for potential confounding factors.

Background: In trauma patients, pancreatic injury is rare; however, if undiagnosed, it is associated with high morbidity and mortality rates. Few predictive models are available for the identification of pancreatic injury in trauma patients with elevated serum pancreatic enzymes. In this study, we aimed to construct a model for predicting pancreatic injury using a decision tree (DT) algorithm, along with data obtained from a population-based trauma registry in a Level I trauma center. Methods: A total of 991 patients with elevated serum levels of amylase (>137 U/L) or lipase (>51 U/L), including 46 patients with pancreatic injury and 865 without pancreatic injury between January 2009 and December 2016, were allocated in a ratio of 7:3 to training (n = 642) or test (n = 269) sets. Using the data on patient and injury characteristics as well as laboratory data, the DT algorithm with Classification and Regression Tree (CART) analysis was performed based on the Gini impurity index, using the rpart function in the rpart package in R. Results: Among the trauma patients with elevated amylase or lipase levels, three groups of patients were identified as having a high risk of pancreatic injury, using the DT model. These included (1) 69% of the patients with lipase level ≥306 U/L; (2) 79% of the patients with lipase level between 154 U/L and 305 U/L and shock index (SI) ≥ 0.72; and (3) 80% of the patients with lipase level

BACKGROUND Harvesting soft tissue from a previously transferred flap allows for flap reshaping and simultaneously raising tissue for a secondary procedure. This is done without increasing the number of donor sites and is therefore a very attractive reconstructive option. METHODS Between March of 2011 and October of 2013, the authors performed 60 recycle flaps on 60 patients (three women and 57 men) who had undergone previous flap reconstruction (52 free and eight pedicled). The recycle flaps were raised as either random pattern or perforator flaps. Mean time between primary reconstruction and the recycle procedure was 28.3 months (range, 6 months to 20 years), and the mean age of our patients was 57 years (range, 21 to 78 years). RESULTS Of 60 recycle flaps raised for secondary reconstruction, 58 survived completely (97 percent). Two cases of total flap necrosis were encountered resulting from pedicle damage during attempted perforator dissection within a previously irradiated flap. Twenty-nine flaps were raised as random pattern flaps, 29 were raised as pedicled perforator flaps (20 with perforator skeletonization), and two were raised as free perforator flaps. CONCLUSIONS There are a number of ways to safely "recycle" the soft tissues used in a previous reconstruction. This provides new tissue for a secondary procedure while debulking and refining the primary flap. Raising perforator flaps from previously irradiated flaps is, however, technically challenging and carries a high risk of flap necrosis (40 percent in our series) and should be advised against. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

The development of a postoperative orocutaneous fistula (OCF) or pharyngocutaneous fistula (PCF) in the irradiated tissues of patients with head and neck cancer represents a high burden of morbidity for the patient. With high postoperative recurrence rates, these fistulae result in a reconstructive challenge for the plastic surgeon. In this study, we propose a new double-layer design to successfully repair these fistulae in a 1-stage reconstruction.Twelve patients with an average age of 56 years (range, 45-67 years) were operated on between January 2006 and December 2012 using this double-layer single-stage technique. All patients had received postoperative radiotherapy after their initial reconstruction. A circumferential turnover flap was designed and raised from the skin surrounding the fistula to recreate inner lining using a tension-free, water-tight repair. No debridement of the fistula itself was performed. The second-layer of the reconstruction, which represents the outer lining, was achieved with either a local or a free flap.Fistula size ranged from 0.8 × 0.5 cm to 3 × 3.2 cm with a mean size of 2 cm(2) . The outer lining was achieved using a free flap in 5 cases and a local flap in 7 cases. All the flaps survived completely with no cases of postoperative infection, however, 1 case was complicated by mandibular plate exposure necessitating its removal. No major complication or recurrence has yet been encountered in any of our patients with a mean follow-up of 28 months (range, 12-78 months).This 1-stage double-layer design can provide a reliable and relatively straightforward means of repairing OCF and PCF in the irradiated tissues of patients with head and neck cancer. © 2015 Wiley Periodicals, Inc. Head Neck 38: E353-E359, 2016.

Background We profiled the expression of circulating microRNAs (miRNAs) in mice using Illumina small RNA deep sequencing in order to identify the miRNAs that may potentially be used as biomarkers to distinguish between gram-negative and gram-positive bacterial infections. Results Recombinant-specific gram-negative pathogen Escherichia coli (Xen14) and gram-positive pathogen Staphylococcus aureus (Xen29) were used to induce bacterial infection in mice at a concentration of 1 × 108 bacteria/100 μL of phosphate buffered saline (PBS). Small RNA libraries generated from the serum of mice after exposure to PBS, Xen14, Xen29, and Xen14 + Xen29 via the routes of subcutaneous injection (I), cut wound (C), or under grafted skin (S) were analyzed using an Illumina HiSeq2000 Sequencer. Following exposure to gram-negative bacteria alone, no differentially expressed miRNA was found in the injection, cut, or skin graft models. Exposure to mixed bacteria induced a similar expression pattern of the circulating miRNAs to that induced by gram-positive bacterial infection. Upon gram-positive bacterial infection, 9 miRNAs (mir-193b-3p, mir-133a-1-3p, mir-133a-2-3p, mir-133a-1-5p, mir-133b-3p, mir-434-3p, mir-127-3p, mir-676-3p, mir-215-5p) showed upregulation greater than 4-fold with a p-value

Background: The diagnosis of diabetic hyperglycemia (DH) does not preclude a diabetes patient from having a stress-induced hyperglycemic response. This study aimed to define the optimal level of elevated glucose concentration for determining the occurrence of stress-induced hyperglycemia (SIH) in patients with diabetes. Methods: This retrospective study reviewed the data of all hospitalized trauma patients, in a Level I trauma center, from 1 January 2009 to 31 December 2016. Only adult patients aged ≥20 years, with available data on serum glucose and glycated hemoglobin A1c (HbA1c) levels upon admission, were included in the study. Long-term average glucose levels, as A1c-derived average glucose (ADAG), using the equation, ADAG = ((28.7 × HbA1c) − 46.7), were calculated. Patients with high glucose levels were divided into three SIH groups with diabetes mellitus (DM), based on the following definitions: (1) same glycemic gap from ADAG; (2) same percentage of elevated glucose of ADAG, from which percentage could also be reflected by the stress hyperglycemia ratio (SHR), calculated as the admission glucose level divided by ADAG; or (3) same percentage of elevated glucose as patients with a defined SIH level, in trauma patients with and without diabetes. Patients with incomplete registered data were excluded. The primary hypothesis of this study was that SIH in patients with diabetes would present worse mortality outcomes than in those without. Detailed data of SIH in patients with diabetes were retrieved from the Trauma Registry System. Results: Among the 546 patients with DH, 332 (32.0%), 188 (18.1%), and 106 (10.2%) were assigned as diabetes patients with SIH, based on defined glucose levels, set at 250 mg/dL, 300 mg/dL, and 350 mg/dL, respectively. In patients with defined cut-off glucose levels of 250 mg/dL and 300 mg/dL, SIH was associated with a 3.5-fold (95% confidence interval (CI) 1.61–7.46; p = 0.001) and 3-fold (95% CI 1.11–8.03; p = 0.030) higher odds of mortality, adjusted by sex, age, pre-existing comorbidities, and injury severity score, than the 491 patients with diabetic normoglycemia (DN). However, in patients with a defined cut-off glucose level of 350 mg/dL, adjusted mortality in SIH in DM was insignificantly different than that in DM. According to the receiver operating characteristic (ROC) curve analysis, a blood sugar of 233 mg/dL, a glycemic gap of 79 (i.e., blood sugar of 251 mg/dL), and a SHR of 1.45 (i.e., blood sugar of 250 mg/dL) were identified as cut-offs for mortality outcomes, with AUCs of 0.622, 0.653, and 0.658, respectively. Conclusions: In this study, a cut-off glucose level of 250 mg/dL was selected to provide a better definition of SIH in DM than glucose levels of 300 mg/dL or 350 mg/dL.

ObjectivesTo provide an overview of the demographic characteristics of patients with positive blood alcohol concentration (BAC) and to investigate the performance of brain CT scans in these patients.DesignCross-sectional study.SettingTaiwan.Participants2192 patients who had undergone a test for blood alcohol of 13 233 patients registered in the Trauma Registry System between 1 January 2009 and 31 December 2012. A BAC level of 50 mg/dL was defined as the cut-off value. Detailed information was retrieved from the patients with positive BAC (n=793) and was compared with information from those with a negative BAC (n=1399).Main outcome measuresGlasgow Coma Scale (GCS) and Injury Severity Score (ISS) as well as the performance and findings of obtained brain CT scans.ResultsPatients with positive BAC had a higher rate of face injury, but a lower GCS score, a lower rate of head and neck injury, a lower ISS and New Injury Severity Score. Alcohol use was associated with a shorter length of hospital stay (8.6 vs 11.4 days, p=0.000) in patients with an ISS of ConclusionsPatients who consumed alcohol tended to have a low GCS score and injuries that were less severe. However, given the significantly low percentage of positive findings, brain CT might be overused in these patients with less severe injuries.

Background The trapezius myocutaneous flap is an established reconstructive option in head and neck cases The authors present their experience with 10 trapezius perforator flaps, all raised using a freestyle technique of perforator dissection, to successfully reconstruct both local and distant soft-tissue defects. Methods Ten patients underwent soft-tissue reconstruction using trapezius perforator flaps. After mapping the perforator with a handheld Doppler device at the intersection of a horizontal line drawn 6 to 8 cm inferior to the scapular spine and a vertical line drawn 8 to 9 cm lateral to the midline of the back, perforator flaps were raised in a freestyle fashion, with complete preservation of the trapezius muscle. The flap can be pedicled into local defects or transferred as a free flap. Results Six flaps were elevated as pedicled flaps and four were transferred as free flaps. Flap size ranged from 6 × 4 cm to 25 × 15 cm. The pedicle length ranged from 4 to 14 cm. The pedicle originated from the dorsal scapular artery. In one case, the authors converted from a pedicled flap to a free flap secondary to insufficient pedicle length. All donor sites were closed directly. The follow-up period ranged from 4 months to 4 years. All of the flaps survived completely with no major complications, and no patients developed any shoulder dysfunction. Conclusions The trapezius perforator flap is a reliable and versatile reconstructive option that can be used to repair both local and distant soft-tissue defects. The donor-site morbidity is minimal. Clinical question/level of evidence Therapeutic, IV.

This aim of this study was to explore the role of miRNA-146a (miR-146a) and its target genes in endothelial cells. We demonstrated that lipopolysaccharide (LPS) induced the upregulation of miR-146a in human umbilical vein endothelial cells (HUVECs), and that the induction was blocked by silencing toll-like receptors, the adaptor molecule MyD88, and the nonspecific NF-κB inhibitor BAY 11-7082. In addition, knockdown of miR-146a by transfection of the locked nucleic acid antimiR-146a significantly inhibited LPS-induced cell migration and tube formation. A combined analysis of bioinformatics miRanda algorithms and a whole genome expression microarray of immunoprecipitated Ago2 ribonucleoprotein complexes identified 14 potential target genes. Subsequent transfection with the miR-146a precursor pre-miR-146a into HUVECs validated that CARD10 was the target gene of the miR-146a, both at the mRNA and protein levels. Silencing CARD10 inhibited p65 nuclear translocation in the cells receiving LPS stimulation and increased angiogenesis. Therefore, miR-146a may play a role in regulating the angiogenesis in HUVECs by downregulating CARD10, which acts in a negative feedback regulation loop to inhibit the activation of NF-κB that normally impairs angiogenesis.

Meralgia paresthetica (MP) consists of pain or dysthesia in the lateral thigh caused by entrapment of the lateral femoral cutaneous nerve (LFCN) underneath the inguinal ligament. The causes include iliac crest bone graft harvesting, seat belt injury associated with motor vehicle accident, diabetes mellitus, and trauma. The authors present the case of a 50-year-old woman who had a 1-year history of right-sided MP. The patient's history and the results of physical and radiological examinations were otherwise unremarkable except for the finding of a lipoma over the surface of the right sartorius muscle. Electrophysiological studies were interpreted as demonstrating peripheral neuropathy only. Conservative treatment, including heat or ice packing and local anesthetic and steroid injections, failed to control the patient's symptoms. Although sectioning or neurolysis of the LFCN appears to offer good-to-excellent results, the patient underwent excision of the lipoma. The symptoms resolved completely. To the best of the authors' knowledge this is the first case of MP associated with compression caused by a lipoma. The authors conclude that lipoma compression can cause MP, and in such cases, total excision of the lipoma may resolve the condition.

Summary: A 26-year-old woman sustained a traffic accident injury to her left medial malleolus. A soft-tissue defect 15 × 7 cm with exposure of bone was found and underwent free anterolateral thigh flap to cover it. On the second postoperative day, venous congestion occurred and re-exploration was performed. Re-anastomosis of the vein was done after the thrombectomy; unfortunately, the flap did not recover. We found there was a good granulation bed under the failing flap and thinned the failing flap and used it as a full-thickness skin graft. The graft survived completely; 9 months later, the graft site was softer and of good texture. The patient can wear the same size shoes without a debulking procedure. The free flap provided nutrients to the raw surface and nurtured a good granulation bed while it survived for 50 hours; as a result, it was used as “the nutrient flap.” Reuse of the failing free flap as “the nutrient flap” is useful as an alternative backup procedure.

A case of a 22-year-old woman with rare neurologic complications including encephalopathy and acute axonal sensorimotor polyneuropathy in the course of acute pancreatitis is reported. The encephalopathy emerged 3 weeks after the onset of the illness with complete remission being noted 1 week later. The polyneuropathy presented as quadriplegia and respiratory failure that required intubation and partially remitted gradually. There was no pancreatic lesion, no major pancreatic surgery, no sepsis, and no multiple organ failure, all of which had been proposed as the predisposing factors. Severe inflammatory response syndrome (SIRS) that developed during the clinical course of this patient might have induced these neurologic complications.

Despite the rare incidence, occult chronic thrombosis of peroneal veins of the fibula graft during the flap harvest presents a challenge to produce a successful reconstruction. In this article, we present a case of a 54-year-old man with chronic thrombosis of peroneal veins found during the harvest of the free fibula osteocutaneous flap for reconstruction of the mandible defect after tumor ablation. With near-total obliteration of the lumens, a small lumen with residual blood outflow was identified under microscopic magnification. A successful flap transfer was made possible by using the recanalized lumen around the chronic thrombus of the vein for microanastomosis. The pathological analysis of the vein revealed that the recanalized lumens and the endothelial cells-specific CD31 immunohistochemical stain highlighted the endothelium of regenerative lumen around the chronic thrombus. The abundant deposition of thick collagen fibers also suggested a chronic nature of the thrombus. However, although a successful microsurgical free osteocutaneous flap transfer might be possible in the patient with lower-limb chronic peroneal vein thrombosis, a careful preoperative evaluation with imaging study is recommended for high-risk patients.

Background Knockout of either toll-like receptor 4 (TLR4) or 2 (TLR2) had been reported to delay the Wallerian degeneration after peripheral nerve injury by deterring the recruitment of the macrophages and clearance of myelin debris. However, the impact on the remyelination process is poorly understood. In this study, the effect of TLR2 and TLR4 knockout on the nerve regeneration and on the remyelination process was studied in a mouse model of sciatic nerve crush injury. Results A standard sciatic nerve crush injury by a No. 5 Jeweler forcep for consistent 30 seconds was performed in Tlr4 −/− (B6.B10ScN-Tlr4 lps-del /JthJ), Tlr2 −/− (B6.129-Tlr2tm1Kir/J) and C57BL/6 mice. One centimeter of nerve segment distal to the crushed site was harvested for western blot analysis of the myelin structure protein myelin protein zero (Mpz) and the remyelination transcription factors Oct6 and Sox10 at day 0, 3, 7, 10, 14, 17, 21, 28. Nerve segment 5-mm distal to injured site from additional groups of mice at day 10 after crush injury were subjected to semi-thin section and toluidine blue stain for a quantitative histomorphometric analysis. With less remyelinated nerves and more nerve debris, the histomorphometric analysis revealed a worse nerve regeneration following the sciatic nerve crush injury in both Tlr4 −/− and Tlr2 −/− mice than the C57BL/6 mice. Although there was a delayed expression of Sox10 but not Oct6 during remyelination, with an average 4-day delay in the demyelination process, the subsequent complete formation of Mpz during remyelination was also delayed for 4 days, implying that the impaired nerve regeneration was mainly attributed to the delayed demyelination process. Conclusions Both TLR4 and TLR2 are crucial for nerve regeneration after nerve crush injury mainly by delaying the demyelination but not the remyelination process.

The aim of this study was to investigate and compare the injury characteristics, severity, and outcome between underweight and normal-weight patients hospitalized for the treatment of all kinds of trauma injury.This study was based on a level I trauma center Taiwan.The detailed data of 640 underweight adult trauma patients with a body mass index (BMI) of BMI ≥ 18.5 kg/m) were retrieved from the Trauma Registry System between January 1, 2009, and December 31, 2014. Pearson's chi-square test, Fisher's exact test, and independent Student's t-test were performed to compare the differences. Propensity score matching with logistic regression was used to evaluate the effect of underweight on mortality.Underweight patients presented a different bodily injury pattern and a significantly higher rate of admittance to the intensive care unit (ICU) than did normal-weight patients; however, no significant differences in the Glasgow Coma Scale (GCS) score, injury severity score (ISS), in-hospital mortality, and hospital length of stay were found between the two groups. However, further analysis of the patients stratified by two major injury mechanisms (motorcycle accident and fall injury) revealed that underweight patients had significantly lower GCS scores (13.8 ± 3.0 vs 14.5 ± 2.0, P = 0.020), but higher ISS (10.1 ± 6.9 vs 8.4 ± 5.9, P = 0.005), in-hospital mortality (odds ratio, 4.4; 95% confidence interval, 1.69-11.35; P = 0.006), and ICU admittance rate (24.1% vs 14.3%, P = 0.007) than normal-weight patients in the fall accident group, but not in the motorcycle accident group. However, after propensity score matching, logistic regression analysis of well-matched pairs of patients with either all trauma, motorcycle accident, or fall injury did not show a significant influence of underweight on mortality.Exploratory data analysis revealed that underweight patients presented a different bodily injury pattern from that of normal-weight patients, specifically a higher incidence of pneumothorax in those with penetrating injuries and of femoral fracture in those with struck on/against injuries; however, the injury severity and outcome of underweight patients varied depending on the injury mechanism. Language: en

Between 1989 and 1994, 42 patients with circumferential skin avulsion of lower extremities were treated with full-thickness skin graft from defatted avulsed flap. Among them, 39 patients were run over by rubber tires during car accidents; the remaining 3 patients were victims of industrial accidents

Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.

Background: The purpose of this study was to use a propensity score-matched analysis to investigate the association between the Osteoporosis Self-Assessment Tool for Asians (OSTA) scores and clinical outcomes of patients with isolated moderate and severe traumatic brain injury (TBI). Methods: The study population comprised 7855 patients aged ≥40 years who were hospitalized for treatment of isolated moderate and severe TBI (an Abbreviated Injury Scale (AIS) ≥3 points only in the head and not in other regions of the body) between 1 January 2009 and 31 December 2014. Patients were categorized as high-risk (OSTA score < −4; n = 849), medium-risk (−4 ≤ OSTA score ≤ −1; n = 1647), or low-risk (OSTA score > −1; n = 5359). Two-sided Pearson’s chi-squared, or Fisher’s exact tests were used to compare categorical data. Unpaired Student’s t-test and Mann-Whitney U test were performed to analyze normally and non-normally distributed continuous data, respectively. Propensity score-matching in a 1:1 ratio was performed using NCSS software, with adjustment for covariates. Results: Compared to low-risk patients, high- and medium-risk patients were significantly older and injured more severely. The high- and medium-risk patients had significantly higher mortality rates, longer hospital length of stay, and a higher proportion of admission to the intensive care unit than low-risk patients. Analysis of propensity score-matched patients with adjusted covariates, including gender, co-morbidity, blood alcohol concentration level, Glasgow Coma Scale score, and Injury Severity Score revealed that high- and medium-risk patients still had a 2.4-fold (odds ratio (OR), 2.4; 95% confidence interval (CI), 1.39–4.15; p = 0.001) and 1.8-fold (OR, 1.8; 95% CI, 1.19–2.86; p = 0.005) higher mortality, respectively, than low-risk patients. However, further addition of age as a covariate for the propensity score-matching demonstrated that there was no significant difference between high-risk and low-risk patients or between medium-risk and low-risk patients, implying that older age may contribute to the significantly higher mortality associated with a lower OSTA score. Conclusions: Older age may be able to explain the association of lower OSTA score and higher mortality rates in patients with isolated moderate and severe TBI.

Background: High-grade blunt hepatic and/or splenic injuries (BHSI) remain a great challenge for trauma surgeons. The main aim of this study was to investigate the characteristics, mortality rates, and outcomes of high-grade BHSI in motorcyclists and car occupants hospitalized for treatment of traumatic injuries in a Level I trauma center in southern Taiwan. Methods: High-grade BHSI are defined as grade III-VI blunt hepatic injuries and grade III-V blunt splenic injuries. This retrospective study reviewed the data of 101 motorcyclists and 32 car occupants who experienced a high-grade BHSI from 1 January 2011 to 31 December 2013. Two-sided Fisher’s exact or Pearson’s chi-square tests were used to compare categorical data, unpaired Student’s t-test was used to analyze normally distributed continuous data, and Mann–Whitney’s U test was used to compare non-normally distributed data. Results: In this study, the majority (76%, 101/133) of high-grade BHSI were due to motorcycle crashes. Car occupants had a significantly higher injury severity score (ISS; 26.8 ± 10.9 vs. 20.7 ± 10.4, respectively, p = 0.005) and organ injured score (OIS; 3.8 ± 1.0 vs. 3.4 ± 0.6, respectively, p = 0.033), as well as a significantly longer hospital length of stay (LOS; 21.2 days vs. 14.6 days, respectively, p = 0.038) than did motorcyclists. Car occupants with high-grade BHSI also had worse clinical presentations than their motorcyclist counterparts, including a significantly higher incidence of hypotension, hyperpnea, tube thoracostomy, blood transfusion >4 units, LOS in intensive care unit >5 days, and complications. However, there were no differences in the percentage of angiography or laparotomy performed or mortality rate between these two groups of patients. Conclusions: This study demonstrated that car occupants with high-grade BHSI were injured more severely, had a higher incidence of worse clinical presentation, had a longer hospital LOS, and had a higher incidence of complications than motorcyclists. The results also implied that specific attention should be paid to those car occupants with high-grade BHSI, whose critical condition should not be underestimated because of the concept that the patients within in a car are much safer.

The authors present a patient with dystrophic epidermolysis bullosa-associated squamous cell carcinoma in the foot. The patient underwent successful reconstruction with a free anterolateral thigh flap based on a perforator with minimal donor site morbidity.

Summary Objective The aim of this study is to suggest that negative pressure wound therapy (NPWT) is an excellent alternative for managing complicated wounds after head and neck reconstruction. Summary background data Management of complicated wounds such as wound infection or persistent saliva leakage from poor wound healing with dead space is challenging in head and neck reconstruction. The NPWT is a useful device widely used in treating many complicated wounds. In this study, we applied this device on complicated wounds after head and neck reconstruction and share our experience and modifications. Methods From January 2004 to December 2009, 13 male patients (mean age: 50.0 years) were included. Eleven patients were reconstructed with free flap transfer and the other two patients received a local flap for repair immediately after tumour ablation. Among them, 12 patients (92%) had complicated wounds with infection and one patient (8%) with partial loss of the free flap. Eight of these 13 patients (62%) had saliva leakage and fistula formation. For those who had a free flap transfer, the vacuum-assisted closure (VAC) system was applied with modifications to the complicated wound 2 weeks later, after better neo-vascularisation around the free flap. Watertight suturing on the mucosal side is needed to ensure air sealing and enhance wound healing acquired by the VAC system. Results All wounds demonstrated adequate control of wound infection, quick obliteration of dead space and rapid growth of granulation tissue under the NPWT. Eleven patients (85%) had wound healing with secondary intention; one (8%) needed a further skin grafting; and one patient (8%) needed a free flap transfer due to partial flap loss in a severe wound infection even after the NPWT application. The average duration of the NPWT usage was 10.8 days (4–24 days); most of the wounds healed within 1 week after the NPWT application. Conclusion The NPWT is an excellent alternative for managing complicated wounds after head and neck reconstruction. It is safe and comfortable for the patient and provides good results in infection control, dead space obliteration and improvement of wound healing.

To determine whether anteromedial thigh (AMT) flaps are a good choice for reconstruction in cases in which no sizable skin perforator is found in anterolateral thigh (ALT) flap dissection or ALT flaps have been previously harvested.From February 2006 to August 2008, 17 free AMT flaps were used to reconstruct soft tissue defects of the head and neck. We recorded the age and sex of the patients, sites of primary tumor, tumor stage, size of defect, previous operative conditions, results of flap transfer, and donor-site complications.Of the 17 AMT flaps, 1 flap failed and 1 showed partial necrosis. Venous insufficiency developed in 2 cases, and the flaps were successfully salvaged in both the cases. The success rate was 94.1%. The AMT flaps were 6 to 20 cm long and 4 to 9 cm wide. The mean length of the pedicle was 7.5 ± 1.0 cm (range, 5-12 cm). Of the 17 donor sites, 6 were closed directly, 9 were closed using split-thickness skin grafts, and 2 were closed using full-thickness skin grafts. Complications and morbidity of the donor site were minimal.Cases in which no sizable perforator is found or an ALT flap has been previously harvested pose an aesthetic challenge, and an AMT flap is a good alternative for performing successful reconstruction in such cases.

Summary Objectives The primary function of the lip is oral competence. The lips are also fundamental in facial aesthetics. Thus in lip reconstruction, it is paramount to achieve both good functional and aesthetic outcomes. Local flaps are able to provide the best tissue match in intermediate and large lip defects. Nevertheless, there has been limited literature on using the musculocutaneous nasolabial flap as a one-stage procedure for lip reconstruction. Methods The authors recruited 21 patients who underwent a one-stage nasolabial musculocutaneous flap reconstruction for lip defects for the study. The modiolus at the mouth angle was preserved and the nasolabial flap was de-epithelised and tunnelled subcutaneously in all patients for reconstructing the lips. Electromyography was performed for 14 flaps to detect muscle activity. Oral competency was assessed using the Drooling Rating Scale and aesthetic outcomes were also analysed postoperatively with the Patient and Observer Scar Assessment Scale. Results All patients successfully underwent lip reconstruction with the musculocutaneous nasolabial flap. There were no flap failures. Electromyographic activity was detected in 10 out of the 14 flaps tested. Oral competencies were well preserved and there were no cases of microstomia. Aesthetic results were also good. Conclusion The nasolabial flap for one-stage reconstruction of lip defects following lip resection is feasible. Good functional and aesthetic outcome can be achieved.

Summary Background The anterolateral thigh (ALT) flap is a workhorse flap in free tissue transfer but an alternative is needed in case of failure, no sizable perforators and for those cases where the ALT flap has already been used. The anteromedial thigh (AMT) flap provides a good amount of soft tissues, not increasing the number of donor sites. In this study, we reviewed a single-centre series of AMT flaps, evaluated the donor-site morbidity and discussed the indications for head and neck reconstruction. Methods From 2006 to 2010, 41 consecutive AMT flaps in 39 patients were done. Donor-site morbidity was evaluated with subjective and functional assessment. At least 6 months after surgery, patients received a standard questionnaire and a bilateral kinetic test was performed to compare the AMT donor leg and the contralateral leg. Results In every case, a sizable perforator was found and an AMT flap was harvested and revascularised. The average size of the flaps was 14.0 ± 5.5 × 6.2 ± 1.5 cm. The mean pedicle length was 8 cm (6–10 cm) and 30 of the perforators (73.2%) were true myocutaneous perforators. Two flaps were lost postoperatively and the assessed success rate was 95%. Donor-site morbidity evaluation showed very good subjective perception and good kinetic functional tests. No impairment in daily activity was found. Conclusion The AMT flap is a very good and reliable option whenever the ALT flap is not available. It does not increase the number of donor sites, preserving a good lower-limb function. Levels of Evidence Therapeutic study: level III.

To elucidate the risk factors for a subsequent vertebral compression fracture following percutaneous vertebroplasty, we analyzed the potential predictors of vertebral compression fractures adjacent to or remote from fractures previously treated with percutaneous vertebroplasty.This is a retrospective cohort study.A major concern after percutaneous vertebroplasty in patients with osteoporosis is the occurrence of subsequent vertebral compression fractures in the untreated vertebral bodies. The risk factors for the development of subsequent vertebral compression fractures after percutaneous vertebroplasty are unclear.Two hundred four consecutive patients underwent percutaneous vertebroplasty for acute vertebral compression fractures between January 2007 and December 2008. Forty-nine patients were excluded. Subsequent vertebral compression fractures were diagnosed by bone edema changes on magnetic resonance imaging. Patient's demographic data were used for univariate and multivariable binary logistic regression analyses.Forty-three (27.7%) of the 155 patients had subsequent vertebral compression fractures within 2 years of percutaneous vertebroplasty, with 21 (48.8%) of these patients having fractures detected within 3 months. Adjacent vertebral compression fractures tended to occur sooner, although not significantly (log-rank test, P = 0.112). On multivariate analyses, only the T-score of bone mineral density was significantly associated with subsequent vertebral compression fractures (P0.0001; odds ratio = 0.27; 95% confidence interval, 0.15-0.49).The only risk factor significantly associated with subsequent vertebral compression fractures following percutaneous vertebroplasty was a low bone mineral density T-score. Patients with lower bone mineral density have a higher incidence of vertebral compression fractures and thus need more intensive clinical and radiological follow-up.

Background The free fibular flap has become the workhorse flap for composite mandibular defect reconstruction. As advancements in microsurgery have improved flap survival, greater interest has shifted toward flap refinements to avert donor-site morbidities. Methods A total of 27 free fibular flaps used for mandible reconstruction were studied prospectively. Of the 27 flaps, 18 suprafascial and nine subfascial dissections were performed. A questionnaire was developed and completed by all patients to assess qualitative aspects of donor-site morbidity and function. Quantitative studies focused on bilateral isokinetic testing of each patient's lower extremities by comparing and quantifying the ankle function. Results For the subfascial group, 42 percent of patients complained of pain and alteration in sensation. These donor-site morbidities within the suprafascial group were negligible. Using the Wilcoxon rank sum test, scores obtained from the questionnaires were analyzed, with significant differences seen in wound problems/cosmetic appearance between the two groups (p = 0.0114). For the subfascial group, the donor leg showed significantly less range of motion in plantar-flexion exercises (p = 0.03). Comparing the isokinetic examination results of the suprafascial and subfascial groups, a significant decrease in ankle dorsiflexion, plantar flexion, and foot eversion was evident in the subfascial group. Conclusions The qualitative or subjective perception of donor-site morbidity, for the suprafascial method of fibular flap harvest, is relatively low. Quantitative analysis revealed that this method did not cause decreases in ankle function, and it had superior contour and aesthetic outcomes compared with the conventional, subfascial method. Clinical question/level of evidence Therapeutic, II.(Figure is included in full-text article.).

In addition to the traditional lithotripsy treatment, extracorporeal shockwaves (ESWs) have been shown to be effective in the treatment of certain musculoskeletal disorders and in enhancing skin flap neovascularization. However, relatively little is known about its effect on melanocytes. To investigate its effect on the melanogenic activity of cultured melanocytes, mouse B16F10 melanocytes were treated with defocused ESWs of different energies (15, 21, and 27 kV) and at different doses (300 and 600 impulses). Cell viability was measured 1 and 24 h after treatment. Melanin content was measured and compared against a standard curve generated with fungal melanin. Cellular tyrosinase activity was calculated with the 3,4-dihydroxyphenylalanine (DOPA) oxidase assay. The results demonstrated that ESW treatment reduced cell viability. Our results also indicated that the overall decrease in cell viability lasted for 6 days. After ESW treatment with 300 or 600 impulses at 21 kV, no significant change in melanin content or tyrosinase activity of the B16F10 melanocytes was noted as compared to those of the control. The present study suggests that ESW treatment does not alter the melanogenic activity of the cultured melanocytes.

This study was designed to determine the in vitro angiogenic ability of far-infrared (FIR) radiation in the skin-derived cultured human microvascular endothelial cells and to elucidate the role of mitogen-activated protein kinases (MAPKs) in this process. The results revealed that FIR radiation from a WS(TM) TY301 FIR emitter activated p38 and extracellular signal-regulated kinase (ERK), but not Akt or c-Jun N-terminal protein kinases (JNK), and significantly promoted angiogenesis by increasing tube formation in Matrigel and the migration of cells across an eight micron polyester filter. The addition of 50 μM PD98059, a MEK inhibitor, significantly inhibited the activation of ERK and the enhanced angiogenesis; in contrast, the inhibition of p38 phosphorylation did not inhibit the enhanced angiogenesis. After FIR radiation, there was no increase in vascular endothelial growth factor (VEGF) isoforms (VEGF-A, -B, -C and -D) mRNA and VEGF protein, no increase phosphorylation of endothelial nitric oxide synthase (eNOS) detected using Western blotting, and no increase in NO production detected using flow cytometry in cells pre-incubated with the cell-permeable NO-binding dye diluted 4-amino-5-methylamino-2', 7'-difluorofluorescein diacetate (DAF-FM DA). This study revealed that FIR radiation possesses in vitro angiogenic activity via the activation of the MEK/ERK but not the VEGF/Akt/eNOS-dependent signaling pathways.

Heme oxygenase-1 (HO-1) expression, in response to various stimuli, has been generally reported to protect against cellular stress. However, we previously demonstrated simvastatin-induced HO-1-exaggerated nuclear factor kappa beta (NF-κβ) activation and superoxide production on exposure to lipopolysaccharide (LPS). The addition of the iron chelator, desferrioxamine, to reduce the accumulation of ferric iron from heme by HO-1 resulted in a blockade of aggravated superoxide production. In this study, we demonstrated that, unlike simvastatin, neither atorvastatin- nor rosuvastatin-induced HO-1 upregulation resulted in increased NF-κβ activation and superoxide production of Neuro-2A cells against LPS. Moreover, increased superoxide formation by either atorvastatin or rosuvastatin, in the presence or absence of LPS, could not be reduced by the addition of desferrioxamine, unlike simvastatin. In contrast to our previous experiment, in which simvastatin activated ERK and p38, but not JNK or Akt, both atorvastatin and rosuvastatin phosphorylated ERK, but not p38. Inhibition of p38 activation by 5 μM of SB203580 effectively reduced exaggerated HO-1 upregulation in cells pretreated with simvastatin, but not atorvastatin or rosuvastatin, plus exposure to LPS. The addition of an ERK inhibitor (50 μM of PD98059) did not decrease HO-1 upregulation in cells following any statin pretreatment. Further, the effect of simvastatin on primary cultures of cortical neurons was also different from that on Neuro-2A cells, as HO-1 upregulation did not result in exaggerated NF-κβ activation and superoxide production. This study demonstrated the involvement of p38 in the differential induction of HO-1 by different statins and showed the different physiological relevance of experiments on different cell types.

Background To compare the microRNA (miRNA) expression profiles in neurons and innervated muscles after sciatic nerve entrapment using a non-constrictive silastic tube, subsequent surgical decompression, and denervation injury. Methods The experimental L4-L6 spinal segments, dorsal root ganglia (DRGs), and soleus muscles from each experimental group (sham control, denervation, entrapment, and decompression) were analyzed using an Agilent rat miRNA array to detect dysregulated miRNAs. In addition, muscle-specific miRNAs (miR-1, -133a, and -206) and selectively upregulated miRNAs were subsequently quantified using real-time reverse transcription-polymerase chain reaction (real-time RT-PCR). Results In the soleus muscles, 37 of the 47 miRNAs (13.4% of the 350 unique miRNAs tested) that were significantly downregulated after 6 months of entrapment neuropathy were also among the 40 miRNAs (11.4% of the 350 unique miRNAs tested) that were downregulated after 3 months of decompression. No miRNA was upregulated in both groups. In contrast, only 3 miRNAs were upregulated and 3 miRNAs were downregulated in the denervated muscle after 6 months. In the DRGs, 6 miRNAs in the entrapment group (miR-9, miR-320, miR-324-3p, miR-672, miR-466b, and miR-144) and 3 miRNAs in the decompression group (miR-9, miR-320, and miR-324-3p) were significantly downregulated. No miRNA was upregulated in both groups. We detected 1 downregulated miRNA (miR-144) and 1 upregulated miRNA (miR-21) after sciatic nerve denervation. We were able to separate the muscle or DRG samples into denervation or entrapment neuropathy by performing unsupervised hierarchal clustering analysis. Regarding the muscle-specific miRNAs, real-time RT-PCR analysis revealed an ~50% decrease in miR-1 and miR-133a expression levels at 3 and 6 months after entrapment, whereas miR-1 and miR-133a levels were unchanged and were decreased after decompression at 1 and 3 months. In contrast, there were no statistical differences in the expression of miR-206 during nerve entrapment and after decompression. The expression of muscle-specific miRNAs in entrapment neuropathy is different from our previous observations in sciatic nerve denervation injury. Conclusions This study revealed the different involvement of miRNAs in neurons and innervated muscles after entrapment neuropathy and denervation injury, and implied that epigenetic regulation is different in these two conditions.

Although serum tau protein levels increase following TBI, the time course is unknown. The aim of the present study was to determine whether serum tau protein levels increased in both a severity-dependent and time-dependent manner in an experimental model of rat traumatic brain injury (TBI).A total of 24 Sprague-Dawley rats were subjected to varying grades of TBI using a contusion injury model on the right parietal cortex. Enzyme-linked Immunoabsorbent Assay (ELISA) analysis for serum was performed at 15 min pre-injury, 1, 6, 24, 48, and 168 h post-injury. Immunoblotting for serum tau protein, neurological evaluation and histological observation were also performed.Tau protein levels rapidly increased after 1 h in both mild and severe TBI groups (p0.001), and declined after 6 h. In the sham-operated group, tau protein levels did not change significantly after TBI. Tau protein levels were severity-dependent at 1 and 6 h after TBI. The levels were higher in the severe TBI group than in the mild TBI group at 1 h (p0.001) and 6 h (p0.001).Serum tau protein levels were severity-dependent and time-dependent at 1 and 6 h after TBI. However, the serum tau protein may not be a useful marker 24 h after TBI.

Meralgia paresthetica (MP) consists of pain or dysthesia in the lateral thigh caused by entrapment of the lateral femoral cutaneous nerve (LFCN) underneath the inguinal ligament. The causes include iliac crest bone graft harvesting, seat belt injury associated with motor vehicle accident, diabetes mellitus, and trauma. The authors present the case of a 50-year-old woman who had a 1-year history of right-sided MP. The patient's history and the results of physical and radiological examinations were otherwise unremarkable except for the finding of a lipoma over the surface of the right sartorius muscle. Electrophysiological studies were interpreted as demonstrating peripheral neuropathy only. Conservative treatment, including heat or ice packing and local anesthetic and steroid injections, failed to control the patient's symptoms. Although sectioning or neurolysis of the LFCN appears to offer good-to-excellent results, the patient underwent excision of the lipoma. The symptoms resolved completely. To the best of the authors' knowledge this is the first case of MP associated with compression caused by a lipoma. The authors conclude that lipoma compression can cause MP, and in such cases, total excision of the lipoma may resolve the condition.

A reverse anterolateral thigh island flap with the dimensions of 6 x 3, 15 x 6, and 26 x 8 cm, respectively, was elevated in 3 patients to repair the skin defects in the knee resulting from crush injuries. The pedicle of the flap was isolated in a retrograde fashion along the descending branch of the lateral circumflex femoral artery to obtain sufficient length until the pivot point was reached. The distal point of the defect to which the flap could reach for the reconstruction was 12 cm below the knee. All flaps survived, but skin necrosis occurred in the margins of those 2 large flaps. With a wide arc of rotation and sufficient skin paddle, the reverse anterolateral thigh island flap based on reverse flow is a good option for repairing skin defect around the knee; however, a staged or delayed operation might be considered in elevating a large flap.

To validate the hypothesis that the reconstruction of the missing segment of the fibula using a redundant split fibular graft after a vascularized fibular flap transfer may have a better effect on ankle function. Of the 24 head and neck cancer patients who received a free fibula flap for mandible reconstruction, 14 patients underwent the conventional method of donor site closure, in which the redundant fibular bone was discarded (Group I). Ten patients underwent longitudinal osteotomy of the redundant non-vascularized fibular portion to bridge the donor site defect (Group II). Postoperative subjective satisfaction level was evaluated with a self-constructed questionnaire in 10 parameters (ambulation with assistance, ankle instability, ankle stiffness, muscle weakness, leg edema, foot numbness, ankle pain, other sites of pain besides the ankle, and restriction to run) and the 4 voluntary motions (dorsiflexion, plantar flexion, eversion, and inversion) of both ankles were measured using a CYBEX II dynamometer. The muscle peak torque of the donor leg was significantly lower at ankle plantar flexion (P = 0.002), eversion (P = 0.002), and inversion (P = 0.0002) in Group I as well as at dorsiflexion (P = 0.031), plantar flexion (P = 0.016), and inversion (P = 0.002) in Group II against the contralateral non-operated leg. The muscle power was significantly greater when performing ankle eversion (P = 0.049) in those who underwent split fibular bone reconstruction. There was no difference in the subjective satisfaction score between these two groups. The reconstruction of the donor site with a split fibular bone graft led only a slight improvement in ankle eversion.

Background Statins are lipid-lowering agents that are widely used in medical practice. Some studies have demonstrated that statins reduce proinflammatory signaling and have antioxidant and anti-inflammatory effects. The inducible heme oxygenase-1 (HO-1) catalyzes the stepwise degradation of heme to produce equimolar quantities of biliverdin, iron, and carbon monoxide; it has also been suggested to promote the important cholesterol-independent cytoprotective action of statins against oxidative insults. However, overexpression of HO-1 may have dual effects under oxidative stress, and the overaccumulation of ferric iron from heme may result in detrimental rather than cytoprotective effects. This study was designed to investigate the effect of a specific statin, simvastatin, and the role of HO-1 on the inflammatory status of the capsule surrounding a silicone shell implant in rats. Methods Sprague-Dawley rats were randomly assigned to different groups according to the indicated implantation time (1 , 2 wk, 1 , 2 , and 3 mo postimplant) and the presence or absence of additional treatment (2mg/kg oral simvastatin daily and/or 2mg/kg HO inhibitor zinc protoporphyrin (ZnPP) by intraperitoneal injection daily). The formed de novo capsular tissue around the silicone implant was dissected away at the indicated time of sacrifice for experiments regarding the HO-1 expression and the inflammatory status. Results We found a biphasic pattern of inflammation of the capsule with increased production of TNF-α, IL-1β, and COX-2, and activation of NF-κB at 1 wk and again at 1 mo postimplantation. Numerous CD68 + monocytes or macrophages were diffusely distributed in the capsule in the early stage but not in the late stage postimplantation. In addition, the implantation procedure induced HO-1 expression, which was significantly up-regulated in the first 2 wk but decreased after 1 mo. Although daily feeding of the rats with simvastatin at 2mg/kg induced HO-1 expression in the capsule throughout the experimental period, simvastatin treatment failed to reduce the production of TNF-α, IL-1β, and COX-2, or limit NF-κB activation in the early or late stages after implantation. Additionally, simvastatin treatment did not decrease the amount of CD68 + cells distributed in the capsule at 1 wk postimplantation. HO-1 up-regulation by simvastatin treatment or down-regulation by additional injection of ZnPP did not demonstrate significant correlation with the inflammatory status of the capsule. Conclusion Simvastatin failed to reduce inflammation of the capsule surrounding a silicone shell implant. Although simvastatin induced HO-1 expression throughout the experimental time, up-regulated HO-1 expression could not be attributed to the inflammatory status of the capsule.

Background To predict the severity of nerve traction injury by skin biopsy with quantification of intraepidermal nerve fibers density (IENFD). Methods Traction injuries to the right sciatic nerve of Sprague-Dawley rats with the use of different weights (0, 25, 50, 100, 200, 400, and 600 g) were performed. Sham operations were performed on the left sciatic nerve. After a period of 7 days, IENFD derived from quantification of protein gene product 9.5-immunoreactive intraepidermal nerve fibers of the hindpaw skin were calculated to compare with numbers of intact teased fibers of tibia nerve. Results There were 100% +/- 0%, 94% +/- 5%, 52% +/- 8%, 48% +/- 6%, 42% +/- 7%, 9% +/- 3%, and 0% +/- 0% of teased nerve fibers remained intact after traction injury with 0 g, 25 g, 50 g, 100 g, 200 g, 400 g, and 600 g weights, respectively. When compared with IENFD of the control rats (ipsilateral paw: 21.6 +/- 0.6; contralateral paw: 20.1 +/- 0.8 fibers/mm), there were loss of nearly half of the small fibers after 50 g, 100 g, and 200 g weight traction injury in ipsilateral paw (10.1 +/- 1.2, 7.4 +/- 1.5, and 8.3 +/- 2.2 fibers/mm, respectively) and contralateral paw (11.4 +/- 0.9, 9.6 +/- 0.6, and 10.0 +/- 1.5 fibers/mm, respectively). After 400 g and 600 g weight traction injury, there was severe (0.2 +/- 0.2 fibers/mm) to complete destruction of the small fibers in ipsilateral paw and marked reduction in contralateral paw (5.5 +/- 0.7 and 4.3 +/- 0.7 fibers/mm, respectively). Conclusions With the ability to classify the nerve traction injury into a mild, moderate, or severe injury, correlations can be made between skin biopsy with IENFD and the severity of nerve traction injury. However, the extent of nerve injury cannot be differentiated within group of moderate injury with the use of three different traction weights.

Acute intermittent porphyria (AIP) is an inherited metabolic disease that can affect the autonomic, peripheral and central nervous systems. Pancreatic diseases assocated with AIP is rarely reported. We report here a 60-year-old non-alcoholic male who had typical manifestations of AIP, including abdominal pain, constipation, tachycardia, hypertension, mental disturbances, psychiatric manifestations, seizures, peripheral neuropathy, and excessive excretion of porphyrin precursors in urine. Increases of serum amylase and lipase, as well as mild pancreatic edema on ultrasonography, were noted during the acute attack of AIP, suggesting concomitant acute pancreatitis. In this patient, brain magnetic resonance imaging revealed reversible multifocal cerebral lesions resembling a posterior reversible encephalopathy syndrome (PRES) during the acute attack of AIP. Because the clinical manifestations of acute pancreatitis could be present with an acute attack of AIP, early confirmation of diagnosis is mandatory to effectively manage the attack and avoid inappropriate treatment.

Background The aim of this study is to assess the efficacy of pulsed RF lesioning of cervical medial branches in patients with whiplash-related chronic cervical zygapophysial joint pain in whom other conservative treatments failed. Methods Cervical zygapophysial joint pain was confirmed in 14 patients undergoing double diagnostic blocks. These patients underwent pulsed RF lesioning of the cervical medial branches. Pulsed RF procedures were performed in 2 cycles of 180 seconds after localization under fluoroscopy guide. Results Twelve (85.7%) patients had substantial pain relief at 1 month. Eleven (78.3%) patients still had more than 60% pain relief at 6 months. Only 5 (35.7%) patients recurred within 12 months. At 12-month follow-up, 9 (64.3%) patients had significant pain improvement. Medication requirements decreased in 13 (92.8%) patients at 1 month, 12 (85.7%) patients at 6 months, and 10 (71.4%) patients at 12 months. Conclusions Pulsed RF of cervical medial branches is a potential treatment for patients with chronic whiplash-related cervical zygapophysial joint pain that failed other conservative treatments. This treatment provides long-lasting pain relief and reduces pain medication requirements.

The study was carried out to investigate the loss of small fibers during entrapment neuropathy and their regeneration after surgical decompression. Entrapment neuropathy was mimicked in a rat model by wrapping the right sciatic nerve of Sprague-Dawley rats with a silastic tube of 1.3 mm inner diameter. A sham operation was performed on the left side. Additional naive rats were used as controls. In the subgroup of rats that received surgical decompression, removal of the tube was performed six months later. Intra-epidermal nerve fiber density (IENFD) was quantified by measuring protein gene product 9.5-immunoreactive epidermal nerve fibers in bilateral hindpaws. The results showed progressive reduction of IENFD after 1, 3, and 6 months of nerve entrapment (e1m, e3m and e6m): naive rats, 20.04+/-2.26 (e1m), 19.39+/-2.38 (e3m), 20.45+/-2.40 (e6m); right side with entrapment, 12.12+/-2.12 (e1m), 6.27+/-1.02 (e3m), 1.83+/-0.48 (e6m); left side after sham procedure, 13.72+/-2.20 (e1m), 8.59+/-1.37 (e3m), 4.56+/-1.07 (e6m) fibers/mm. Small fiber deficit was present both on the side with the entrapment and the contralateral side that had undergone the sham procedure. Increased IENFD was found at 1 and 3 months post-decompression (d1m and d3m), but failed to return to that of the naive rats: naive rats, 20.38+/-2.24 (d1m), 18.94+/-2.24 (d3m); entrapment, 7.00+/-1.14 (d1m), 6.97+/-1.40 (d3m); sham, 6.41+/-1.16 (d1m), 9.92+/-1.64 (d3m) fibers/mm. These findings demonstrate progressive degeneration of small fibers during entrapment neuropathy and partial restoration of innervation after decompression. The results also imply that, in addition to the contralateral side, naive controls are mandatory in the study of small fiber loss in entrapment neuropathy.

Heme oxygenase-1 (HO-1) has been suggested as an important mediator of the cholesterol-independent cytoprotection actions of statins, which may be of benefit for the treatment of degenerative neurological diseases and for reduction of infarct volume after cerebral ischemia. Overexpression of HO-1, however, has dual effects under oxidative stress, and the release of ferric iron from heme under these conditions may result in detrimental rather than cytoprotective effects. This study was designed to investigate the effect of simvastatin-induced HO-1 on Neuro 2A cells in response to glucose deprivation. We demonstrated that simvastatin induced a dose- and time-dependent upregulation of HO-1 protein expression in Neuro 2A cells. The induction of HO-1 after simvastatin treatment was mediated by nuclear factor erythroid 2-related factor 2 (Nrf2), which was expressed by Western blots of nuclear fractions and retarded complex formation in the electrophoretic mobility shift assay reaction. In addition, simvastatin activated the extracellular signal-regulated kinase and p38, but not the phosphorylation of c-Jun N-terminal kinase and Akt. Glucose deprivation in the cells pretreated with simvastatin induced more HO-1 expression, and the transcript could be decreased by small interfering RNA for Nrf2. This upregulation of HO-1 was significantly associated with increased apoptosis, manifested as expression at the protein level of 17-kDa cleaved caspase-3 and increased percentage of apoptotic cells shown by flow cytometry. The increased cleaved caspase-3 expression and percentage of apoptotic cells was significantly reduced by the HO inhibitor zinc protoporphyrin. Addition of the iron chelator desferrioxamine also resulted in blockade of the aggravated apoptosis, which implies that iron production from HO-1 activity may play an important role in the increased apoptosis in response to glucose deprivation in neuronal cells pretreated with simvastatin.