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Objective: Skin grafts after negative pressure wound therapy (NPWT) and acellular dermal matrix (ADM) usage have both been useful for treating diabetic foot amputation. We hypothesised that injectable ADM combined with NPWT would be more useful than NPWT only for healing after amputation in patients with diabetic foot ulcers (DFUs). The aim of this study was to investigate the clinical outcomes of injectable ADM combined with NPWT in patients with DFU who have undergone amputation. Method: This retrospective study reviewed patients with infected DFUs who were administered NPWT. Patients were divided into two groups: Group 1 included patients who were treated with NPWT only, while Group 2 included patients who were treated with injectable ADM combined with NPWT. Clinical results including the number of NPWT dressing changes, wound healing duration, and full-thickness skin graft (FTSG) incident rate between the two groups were compared. Results: A total of 41 patients took part in the study (Group 1=20, Group 2=21). The mean number of NPWT dressing changes was significantly lower in Group 2 (8.71±3.77) than in Group 1 (13.90±5.62) (p=0.001). Mean wound healing period was shorter in Group 2 (3.17±1.36 weeks) than in Group 1 (5.47±1.68 weeks) (p=0.001). Finally, the rate of patients who underwent FTSG for complete wound closure was 85% in Group 1, whereas it was only 14.3% in Group 2. Conclusion: In this study, the use of injectable ADM combined with NPWT in patients with DFU who underwent amputation favoured complete wound healing, without the need to resort to the use of skin grafts.

Background: Diabetic foot ulcers (DFUs), a risk factor for infection, remain a difficult clinical complication. Infected DFUs may be associated with lower extremity amputation. To achieve wound healing and avoid amputation, an assortment of dressing materials and negative pressure wound therapy (NPWT) have been used on soft tissue injuries resulting from infected DFUs. A great deal of interest about the use of dressing materials and NPWT in the treatment of DFUs has arisen. However, there have only been a few high-quality studies regarding this topic.Current Concepts: Ideal dressing materials should satisfy certain conditions to alleviate symptoms of DFU infection and enhance the wound healing process. A single dressing material cannot fulfill all of these requirements. Based on clinical trials, different dressing materials must be chosen according to the status of the individual wound environment, including the amount of exudate, degree of pain, severity of the infection, and cost-effectiveness. However, there has been no clear evidence that advanced wound dressing materials are superior to basic dressing materials in wound healing. Recently, NPWT has been used to cover the soft tissue defects of infected DFU with granulation tissue. NPWT may contribute to changing growth factor expression, micro- and macro-deformation, vascular flow, amount of exudate, and the bacterial environment in DFU, despite the unclear mechanism of its role in wound repair.Discussion and Conclusion: Further research to obtain high-quality evidence regarding the benefits of using dressing materials and NPWT is needed. The optimal protocol for DFU and cost-effectiveness should be included in these future studies.

Background: Patellar tendinopathy is a common cause of limitations in daily life activities in young and/or active people. The patellar tendon consists of a complex of collagen fibers; therefore, collagen could be used as a scaffold in the treatment of patellar tendinopathy. Purpose: To evaluate the healing capacity of injected atelocollagen as a treatment scaffold for patellar tendon defect and, hence, its potential for the treatment of patellar tendinopathy. Study Design: Controlled laboratory study. Methods: After receiving a full-thickness patellar tendon defect, 24 New Zealand White rabbits were divided into a control group (without treatment) and an experimental group that received an atelocollagen injection into the defect. Six rabbits from each group were subsequently used for either histologic scoring or biomechanical testing. The Mann-Whitney U test was used to compare histologic evaluation scores and load to failure between the 2 groups. Statistical significance was set at P < .05. Results: The experimental group showed excellent repair of the damaged patellar tendon and good remodeling of the defective area. In contrast, the control group showed defective healing with loose, irregular matrix fibers and adipose tissue formation. A statistically significant difference was found between the 2 groups in both histologic scores and biomechanical tests at postoperative week 12. Conclusion: Injection of atelocollagen significantly improved the regeneration of damaged patellar tendons. Clinical Relevance: Atelocollagen gel injections could be used to treat patellar tendinopathy in outpatient clinic settings.

A cell therapy product of transforming growth factor (TGF)-β1-transduced chondrocytes has been commercialized to treat osteoarthritis of the knee via intra-articular injection. The need for arthroscopic application of the cells to simultaneously treat intra-articular pathologies of knee osteoarthritis is increasingly urgent. The purpose of this study was to optimize TGF-β1-transduced chondrocytes for arthroscopic application. The optimal composition of chondrocytes and thrombin was initially determined by measuring the consolidation time of a diverse ratio of chondrocytes and thrombin mixed with 1 ml of fibrinogen. The consolidation time of the diverse ratio of fibrinogen and atelocollagen mixed with the determined optimal ratio of chondrocytes and thrombin was evaluated. The mixture of the determined optimal ratio of TGF-β1-transduced chondrocytes, atelocollagen, fibrinogen, and thrombin was applied to the cartilage defect of the 3D printed knee joint model arthroscopically. The status of the mixture in the defect was then evaluated. Chondrogenic activities of TGF-β1-transduced chondrocytes mixed with atelocollagen were evaluated. The determined ratio of TGF-β1-transduced chondrocytes to thrombin was 8:2 and that of fibrin to atelocollagen was also 8:2. Excellent maintenance of conformation of the mixture of TGF-β1-transduced chondrocytes, atelocollagen, fibrinogen, and thrombin in the cartilage defect of the 3D printed knee joint model was observed arthroscopically. Increased chondrogenic activities were observed in the group of TGF-β1-transduced chondrocytes mixed with atelocollagen. TGF-β1-transduced chondrocytes can be applied arthroscopically to treat cartilage defects of the knee at an optimized mixing ratio of atelocollagen, fibrinogen, and thrombin.

Category: Trauma Introduction/Purpose: Postoperative malreduction of syndesmotic disruptions in the rotational ankle fractures can make the poor functional outcome. There were many efforts to evaluate the quality of syndesmotic reduction with computed tomography (CT). However, there were few studies to show the acceptable range of syndesmotic reduction with CT. The aim of this study to investigate the reduction of the distal tibiofibular joint after open reduction and positional pinning with anterolateral approach in rotational ankle injuries and show acceptable range of syndesmotic reduction. Methods: This study included axial CT images of 104 patients (104 ankles) with rotational ankle fractures which were obtained in both ankles including uninjured ankle between 2012 February and 2014 June. At 10 mm proximal to the tibial plafond, anterior, middle, posterior shortest distances (aTFD, mTFD, pTFD) between fibula and tibia were measured and compared with those of uninjured ankles preoperatively, immediate postoperatively and at the followup after removal of syndesmotic fixation. The shortest distance from the anterior border of the fibula to the connecting line between most prominent point of anterior tibia and most prominent point of lateral fibula (ATF) were measured and compared in both ankles preoperatively, immediate postoperatively and at the followup after removal of syndesmotic fixation. The clinical outcomes were evaluated with AOFAS hindfoot score and visual analogue scale for pain. Results: Mean preoperative aTFD, mTFD, pTFD were 3.4±0.5 mm, 6.2±2.4 mm, 10.3±2.9 mm respectively. Mean immediate aTFD, mTFD, pTFD were 1.4±0.3 mm, 2.9±0.5 mm, 5.1±2.0 mm respectively. Mean postoperative aTFD, mTFD, pTFD at the followup after pin removal were 2.4±0.5 mm, 3.6±1.0 mm, 6.3±2.9 mm respectively. Mean ATF were 0.5±0.1 postoperatively. Both aTFD and mTFD significantly improved immediate postoperatively and at the followup after removal of syndesmotic fixation. However mean pTFD was widened compared to uninjured ankle. All postoperative clinical outcomes were improved significantly. Conclusion: Open reduction and positional pinning with anterolateral approach in rotational ankle injuries could show the good clinical outcomes and posterior tibiofibular diastasis could be allowed in terms of syndesmotic reduction if there is no anterior translation of fibula with improved anterior and middle tibiofibular distance at the axial CT images.

To evaluate aortoiliac aneurysms repaired with endovascular stent-grafts complicated by hemodynamically significant graft stenosis.Fifty-four patients (52 men, two women; age range, 41-90 years; mean age, 75 years) with aneurysms of the infrarenal aorta (n = 36) or iliac artery (n = 18) underwent repair by means of placement of an endovascular stent-graft. Technical success was evaluated angiographically during and after placement. At follow-up (range, 12-44 months), all patients underwent sequential duplex ultrasonography, helical computed tomography, and physical examination.Stent-grafts were placed successfully in all cases. Stenosis at the internal iliac arterial origin was identified at angiography in 17 patients (31%). Supplemental intragraft stents were placed in 11 patients, and stent-graft angioplasty alone was performed in one patient. Intragraft stents were placed percutaneously in five patients when stenosis was discovered during follow-up.Supplemental intragraft stents were required in 31% of aortoiliac endovascular stent-grafts to correct stent-graft stenosis and preserve long-term function. Placement of a fully supported stent-graft is necessary to repair an aortoiliac aneurysm.

To evaluate the safety and efficacy of the recombinant tissue plasminogen activator alteplase in the clearance of poorly functioning tunneled hemodialysis catheters.We retrospectively reviewed the outcomes of 25 patients who presented with poorly functioning hemodialysis catheters and were treated with alteplase. After confirming fluoroscopically the need for thrombolytic therapy, alteplase was administered over 2 hours as a 2.5-mg/hour/catheter lumen infusion (total 10 mg). Treatment was considered a clinical success if a flow rate of 250 mL or more per minute was established.Clinical success was achieved in each of 25 patients (100%). There were no thrombolytic-related complications. Catheter survival was extended 30 days in 54% of patients and 45 days in 33% of patients.Alteplase is a safe and effective means of producing clearance of blocked tunneled catheters.

Purpose: To determine if limited doses of iodinated contrast significantly worsen the underlying renal insufficiency that had warranted the use of CO2 for diagnostic angiography. Methods: The records of 122 consecutive patients who had undergone CO2 angiography for peripheral vascular disease at our institution over a 5-year period were reviewed. The volume and type of iodinated contrast and the volume of CO2 administered were recorded. Serum creatinine measurements obtained before angiography and from 2 to 3 days after angiography were recorded. Results: One hundred patients had pre-angiography and post-angiography creatinine levels available for analysis (51 CO2 only, 49 CO2 with iodinated contrast). The average pre-treatment creatinine level was 2.8±1.5 mg/dL (range 1.8–6.6) for the CO2 only group and 3.0±1.4 mg/dL (range 1.8–8.2) for the CO2 plus iodinated contrast group (p=0.46). After angiography, the mean change in creatinine was +0.17±0.87 mg/dL for the CO2 only group and +0.03±0.98 mg/dL in the CO2 plus contrast group (p=0.27). Complications included 1 patient with a failing renal transplant who received iodinated contrast and ultimately required return to hemodialysis. A second patient had a transient 1-mg/dL rise of creatinine but did not require dialysis. Conclusions: This study supports the relative safety of CO2 angiography with the limited used of iodinated contrast supplementation for diagnostic studies or interventions in azotemic patients with peripheral vascular disease.

The purpose of this study was to describe our experience with balloon and self-expanding endovascular grafts for the management of thoracic aortic lesions. Between February 1997 and June 1998, 20 endovascular grafts were implanted in 14 patients for the treatment of thoracic aortic aneurysms and pseudoaneurysms. Endovascular procedures were performed using one of four different devices: (1) Dacron-covered balloon-expandable Palmaztrade mark stent, (2) balloon-expandable Palmaz stent-PTFE graft prosthesis (BE-PS), (3) self-expanding internally supported Nitinol Dacron prosthesis (Vanguardtrade mark SE-V), and (4) self-expanding externally supported Nitinol PTFE prosthesis (Excludertrade mark SE-E). The results show that endovascular grafting represents a potentially important alternative therapy to open repair of the thoracic aorta. Self-expanding devices were, in our experience, easier to use and more accurately deployed.

PURPOSE To assess the feasibility of performing uterine artery embolization as an outpatient treatment for symptomatic uterine fibroids. MATERIALS AND METHODS Forty-nine consecutive patients (mean age, 44.5 years; range, 28–54 years) underwent uterine artery embolization during a 12-month period. Embolization was performed with 350–500 μm polyvinyl alcohol particles (44 of 49) or Gelfoam pledgets (five of 49). At discharge, patients were given instructions regarding the constitutional symptoms to expect after embolization. A specific medication regimen consisting of prochlorperazine, ketorolac, meperidine, and hydrocodone was prescribed for relief of these symptoms. All patients were telephoned within 24 hours of discharge. During long-term follow-up, a questionnaire was administered to all patients to evaluate the periprocedural experience. Three-month clinical follow-up was available in 26 patients and 6-month imaging follow-up was available in 16 patients. RESULTS Fourteen patients presented with menorrhagia, six had bulk-related symptoms (abdominal distension, stress incontinence, pelvic pain), and 29 had both. Technical success for bilateral embolization was 98%. Forty-seven of 49 patients were discharged to home 6–8 hours after the procedure; two patients required overnight observation in an ambulatory unit (one because of postprocedure hypertension and one because of a late procedure completion time). At the first follow-up phone call, reported symptoms included pelvic pain/cramping in 83.7% (41 of 49), fatigue in 75.5% (37 of 49), nausea/vomiting in 46.9% (23 of 49), and a nonpurulent vaginal discharge in 18.4% (nine of 49). These symptoms were satisfactorily controlled with discharge medications in 48 of 49 patients. No patients returned to the hospital or visited an emergency room during the first 48 hours after discharge. Forty-six of 49 patients were satisfied with the decision for home discharge. The average uterine volume reduction in 16 patients with 6-month imaging follow-up was 47.5%; 88.5%, of patients (23 of 26) with 3-month clinical follow-up reported improvement or elimination of symptoms. CONCLUSIONS With defined telephone follow-up, staff availability, and a protocol designed to alleviate the postprocedure constitutional symptoms, uterine artery embolization is both safe and effective when performed as an outpatient procedure.

To compare the prevalence of hepatic arterial complications in patients who underwent hepatic arterial chemoembolization for hepatocellular carcinomas before orthotopic liver transplantation with the prevalence of hepatic arterial complications in the total population of liver transplant recipients.Forty-seven patients underwent selective hepatic arterial chemoinfusion with mitomycin C, doxorubicin hydrochloride, and cisplatin combined with embolization. The prevalence rates for hepatic arterial complications, including pseudoaneurysm, stenosis, anastomotic disruption, and thrombosis, were tabulated and compared with results in 1,154 patients who underwent orthotopic liver transplantation but not chemoembolization.Of the 47 patients who had undergone preoperative hepatic arterial chemotherapy, 13% developed hepatic arterial complications within a mean of 7 days after transplantation; an 8% prevalence of hepatic arterial thrombosis was observed. Of the 1,154 patients who underwent orthotopic liver transplantation but not chemotherapy, 6% developed hepatic arterial complications; a 5% prevalence of hepatic arterial thrombosis was observed. There was no statistically significant difference in the prevalence rates for thrombosis and complications between the patients who underwent chemoembolization before orthotopic liver transplantation and those who did not. The mean interval between chemotherapy and orthotopic liver transplantation was 111 days (range, 3-428 days).Patients who undergo hepatic arterial chemotherapy are not at an increased risk of developing hepatic arterial thrombosis or other hepatic arterial complications after orthotopic liver transplantation.

Background. Sickle cell intrahepatic cholestasis is a potentially catastrophic complication of sickle cell anemia. Once acute liver failure develops, transplantation is the only option. We describe a patient with sickle cell intrahepatic cholestasis who underwent liver transplantation. Methods. Data were obtained from the chart. Serial hemoglobin S levels were monitored, and measures were taken to maintain hemoglobin S

Many imaging modalities can be used to evaluate various portosystemic collateral pathways seen in patients with portal hypertension. A knowledge of various typical and atypical pathways is essential for a proper understanding of the disease process. Transjugular transhepatic portographic appearance of such pathways are discussed in detail.

An unusual presentation of mycotic aneurysm is described. In this case, a large thrombosed mycotic aneurysm of the superficial femoral artery was associated with segmental occlusion of the adjacent artery. Small vessels were delineated in the periphery of the aneurysm on angiography.

Effects on ion transport of extracellular Na+ and Cl- ([Na+]o and [Cl-]o, respectively), HCO3(-)-CO2, 8-bromoadenosine 3',5'-cyclic monophosphate (8-BrcAMP), epinephrine, and transport inhibitors were examined in short-circuited rabbit proximal colonic mucosa. Net Na+ flux was independent of Cl- but partially (60%) dependent on HCO3(-)-CO2. Net Cl- flux was partially (70%) dependent on Na+ and totally dependent on HCO3(-)-CO2. Both fluxes peaked between 25 and 60 mM and decreased at higher concentrations. Apical Na+ influx but not Cl- influx obeyed the same pattern. The inhibition resulted from increases in mucosal but not serosal [Na+]o and not from increases in [Cl-]o. Amiloride and benzamil (0.2-0.3 mM) partially inhibited net Na+ absorption, as did 8-BrcAMP, but these effects were independent of the inhibition seen at high [Na+]o. Net Cl- absorption was inhibited by 8-BrcAMP but not by 0.2 mM amiloride. At high [Na+]o and [Cl-]o, there were a residual ion flux suggesting HCO3- secretion and, in the presence of 8-BrcAMP and amiloride or benzamil, net secretions of Na+ and Cl-, the former larger than the latter. Epinephrine, via alpha 2-receptors, reversed the ion-transport effects of high [Na+]o but did not stimulate a mucosal-to-serosal unidirectional HCO3- flux (as shown in rabbit ileum). 4-Acetamido-4'-isothiocyanostilbene-2,2'-disulfonic acid (0.5 mM) and bumetanide (10 microM) had no effect on ion transport. The results suggest 1) Na+ entry via two Na(+)-H+ exchangers, one inhibited by amiloride and cAMP and the other inhibited by high [Na+]o and stimulated by epinephrine; 2) Cl- entry via Cl(-)-HCO3- exchange; 3) HCO3- secretion at high [Na+]o and [Cl-]o; and 4) cAMP-induced secretion of Na+ and Cl- at high [Na+]o and [Cl-]o.

Percutaneous transluminal angioplasty is a commonly performed procedure. The clinical success of such a procedure is determined by the combination of the post-procedure angiographic appearance and the pressure gradient across the lesion. This case demonstrates the importance of recognizing the anatomical variation if proper pressure measurements are to be obtained.

Purpose: Successful endovascular repair of an abdominal aortic aneurysm (AAA) requires the creation of a hemostatic seal between the endograft and the underlying aortic wall. A short infrarenal aortic neck may be responsible for incomplete aneurysm exclusion and procedural failure. Sixteen patients who had an endograft positioned completely below the lowest renal artery and 37 patients in whom a porous portion of an endograft attachment system was deliberately placed across the renal arteries were studied to identify if endograft positioning could impact on the occurrence of incomplete aneurysm exclusion. Methods: Fifty-three patients underwent aortic grafting constructed from a Palmaz balloon expandable stent and an expandable polytetrafluoroethylene (ePTFE) graft implanted in an aorto-ilio-femoral, femoral-femoral configuration. Arteriography, duplex ultrasonography and spiral CT scans were performed in each patient before and after endografting to evaluate for technical success, the presence of endoleaks, and renal artery perfusion. Results: There was no statistically significant difference in patient demography, AAA size, or aortic neck length or diameter between patients who had their endografts placed below or across the renal arteries. However, significantly more proximal aortic endoleaks occurred in those patients with infrarenal endografts (P ≤.05). Median serum creatinine level before and after endografting was not significantly different between the 2 patient subgroups, with the exception of 2 patients who had inadvertent coverage of a single renal orifice by the endograft. Median blood pressure and the requirement for antihypertensive therapy remained the same after transrenal aortic stent grafting. Significant renal artery compromise did not occur after appropriately positioned transrenal stents as shown by means of angiography, CT scanning, and duplex ultrasound scan. Mean follow-up time was 10.3 months (range, 3 to 18 months). Patients who had significant renal artery stenosis (≥50%) before aortic endografting did not show progression of renal artery stenosis after trans-renal endografting. Two patients with transrenal aortic stent grafts had inadvertent coverage of 1 renal artery by the endograft because of device malpositioning, which resulted in nondialysis dependent renal insufficiency. In addition, evidence of segmental renal artery infarction (

In rabbit proximal colon, in vitro addition of phorbol 12,13-dibutyrate (PDB, 10(-7) M) to the serosal bathing medium inhibits mucosal (m)-to-serosal (s) unidirectional Na flux (JsmNa) without altering JsmNa or unidirectional Cl fluxes. Similar results were obtained when amiloride (2 X 10(-4) M) was added to the mucosal bathing medium. No additivity of effect was seen when tissues were exposed to both agents. Measurements with carboxyfluorescein reveal that the two agents cause equal decreases of intracellular pH (pHi), an effect that is dependent on the presence of extracellular Na (Na replacement also decreases pHi). No additivity of pHi effects is seen when both agents are added together. To determine the membrane site of this PDB-inhibitable Na-H exchange, Na influx across the luminal border of proximal colon was measured and was found to be inhibited equally by PDB and amiloride. We conclude that PDB, by activation of protein kinase C, inhibits electro-neutral amiloride-sensitive Na-H exchange in the luminal membrane of proximal colon.