Reconstruction of Large Diaphyseal Defects of the Femur and the Tibia with Autologous Bone

Abstract   Post-traumatic segmental bone defects of the femur and the tibia above the critical size require special attention because conventional bone grafts result in high rates of nonunion. The biological and biomechanical aspects of this challenging surgery, as well as ongoing refinements to achieve mechanically stable bone healing with correct bone alignment are reviewed. Choosing the best appropriate method is mainly dependent on both the location and etiology of the bone defect. Three patients with successful bone reconstruction using two-stage reconstruction with cancellous bone graft, double-barrel free vascularized fibula transfer and distraction osteogenesis are described. Advantages and disadvantages of these methods are discussed in accordance with recent literature.     

The Detrimental Effect of Poor Early Graft Function After Laparoscopic Live Donor Nephrectomy on Graft Outcomes

We undertook this study to assess the rate of poor early graft function (EGF) after laparoscopic live donor nephrectomy (lapNx) and to determine whether poor EGF is associated with diminished long-term graft survival. The study population consisted of 946 consecutive lapNx donors/recipient pairs at our center. Poor EGF was defined as receiving hemodialysis on postoperative day (POD) 1 through POD 7 (delayed graft function [DGF]) or serum creatinine ≥ 3.0 mg/dL at POD 5 without need for hemodialysis (slow graft function [SGF]). The incidence of poor EGF was 16.3% (DGF 5.8%, SGF 10.5%), and it was stable in chronologic tertiles. Poor EGF was independently associated with worse death-censored graft survival (adjusted hazard ratio (HR) 2.15, 95% confidence interval (CI) 1.34–3.47, p = 0.001), worse overall graft survival (HR 1.62, 95% CI 1.10–2.37, p = 0.014), worse acute rejection-free survival (HR 2.75, 95% CI 1.92–3.94, p < 0.001) and worse 1-year renal function (p = 0.002). Even SGF independently predicted worse renal allograft survival (HR 2.54, 95% CI 1.44–4.44, p = 0.001). Risk factors for poor DGF included advanced donor age, high recipient BMI, sirolimus use and prolonged warm ischemia time. In conclusion, poor EGF following lapNx has a deleterious effect on long-term graft function and survival.     

Long-Term Insulin-Independence After Allogeneic Islet Transplantation for Type 1 Diabetes: Over the 10-Year Mark

Results of islet of Langerhans transplantation have markedly improved in recent years, but most patients still lose insulin independence in the long-term. We report herein the longest (over 11 years) case of insulin independence after allogeneic islet transplantation. The subject had a 27-year history of type 1 diabetes and received a single islet-after-kidney graft of 8800 islet equivalents (IEQ)/kg, pooled from 2 donors. Insulin was discontinued by 3 months posttransplant and the patient has remained off insulin ever since. Yearly follow-up studies have revealed normal metabolic control, including normal oral glucose tolerance test (OGTT). Reasons for success may involve choice of immunosuppression, low metabolic demand and low immune responsiveness as suggested by an excellent HLA matching and a high count of circulating regulatory T cells. This observation is so far an exceptional case, but clearly demonstrates the validity of the concept that long-term insulin independence after allogeneic islet transplantation is an achievable target.     

Upregulation of TNF Receptor Type 2 in Human and Experimental Renal Allograft Rejection

An important role of TNF interacting with TNFR2 has been shown in different models of ischemic, nephrotoxic and immune-mediated renal injury. To systematically evaluate the expression of TNFR2 in renal allograft rejection, we investigated human renal allograft biopsies and, in addition, established an experimental transplantation model in rats to verify the human data under standardized conditions.
The expression of TNFR2 was analyzed in 96 human renal allograft biopsies with different disease entities. In a 6-day and a 28-day experimental protocol, TNFR2 was examined in kidney specimens and in the urine of control, uni-nephrectomized and transplanted rats ± cyclosporine treatment (n = 114).
In human biopsies and in rat allografts on day 6 with acute allograft rejection, significantly elevated expression of TNFR2 was observed in tubular epithelial cells, podocytes, B cells and monocytes/macrophages. The expression level was associated with renal function. The TNFR2 expression level at day 28 was significantly lower compared to day 6.
TNFR2 is markedly upregulated both in human and experimental acute renal allograft rejection. Our data are robust and consistent between different species, suggesting a role for TNFR2 in the early course of rejection.     

新型骨组织工程β-TCP／CPPF／PLLA支架复合BMSCs修复节段性骨缺损的影像学研究

目的：将自体骨髓基质细胞（Bone marrow stromal cells,BMSCs）接种到β-TCP／CPPF／PLLA支架上,进行体外复合培养,构建组织工程人工骨,植入兔桡骨大段骨缺损模型中,评估BMSCs／β-TCP／CPPF／PLLA复合体促进成骨的作用。方法：用新西兰大白兔40只,随机分为BMSCs／β-TCP／CPPF,PLL复合物组（A组）、β-TCP／CPPF／PLLA支架组（B组）、空白对照组（C组）共三组,建立兔桡骨双侧大段骨缺损模型,相应植入自体细胞材料复合物和单纯支架材料,空白对照组不作任何处理。术后4、8、12、16周处死动物,摄X线片观察骨缺损修复情况。结果：X线检查结果：A组术后2周可见缺损处有散在的、少量的模糊状骨痂生成,术后4周可见明显的骨生成影像,成云雾状,均匀分布在骨缺损区,术后8周整个缺损区均可见到骨痂生成,成骨现象较4周更加明显,部分髓腔已通,术后12～16周,缺损区已完全为新生的骨组织充填,骨髓腔已完全再通,修复区比正常的桡骨较细。B组、C组术后2～16周,虽有不同程度的成骨现象,但没有完全修复骨缺损区,B组较C组修复明显。X线评分结果：A组在各时期均明显高于B组,差异具有显著性（P〈0．01）。结论：自体BMSCs与β-TCP／CPPF／PLLA复合物移植能修复大节段的骨干缺损。     

应用各类鼻唇沟皮瓣美容修复眶下部缺损

目的：探讨各类鼻唇沟皮瓣在眶下部缺损修复中应用的美学效果。方法：根据眶下部软组织缺损的部位、范围、程度和与同侧鼻唇沟的解剖关系,按整形外科原则选择适合的鼻唇沟皮瓣进行美容修复,包括：局部带蒂皮瓣修复法及皮下蒂皮瓣修复法。结果：共施行手术12例。创面面积1.0cm×1.0cm～3.5cm×2.0cm。术后12例皮瓣全部成活,外形恢复满意,无下睑外翻,皮瓣质地、色泽均与周围皮肤接近,鼻唇沟瓣供区瘢痕隐蔽。结论：根据眶下部皮肤软组织缺损情况应用合适的鼻唇沟皮瓣进行修复,能达到理想的美学效果。     

Neuromodulation and female sexual function: does treatment for refractory voiding symptoms have an added benefit?

Introduction and hypothesis  Women undergoing InterStim implantation for overactive bladder (OAB) or painful bladder syndrome (PBS) were prospectively evaluated to determine if neuromodulation has any effect on female sexual function (FSF). Methods  Sexually active women in our InterStim database completed a female sexual function index (FSFI) preoperatively and at 6 months. Results  Of 105 women, 54 have 6-month follow-up data. Of these, 27 were sexually active preoperatively and at follow-up. The mean (standard deviation (SD)) FSFI improved from 18.7 (6.8) preoperatively to 21.0 (6.0) postoperatively; however, this was not statistically significant (p = 0.220). Subgroup analysis of patients with OAB revealed that mean (SD) FSFI preoperatively was 18.6 (8.0) and 22.4 (6.4) at 6 months (p = 0.257). In the PBS group, mean (SD) FSFI was 18.8 (6.3) preoperatively and 18.7 (5.8) at 6 months (p = 0.98). Conclusions  Neuromodulation does not significantly improve FSF in a heterogenous population. Additional studies are needed to confirm the findings in our study.     

游离肩胛区骨皮瓣在舌和口底及下颌骨联合缺损修复中的应用

目的：介绍游离肩胛区骨皮瓣在舌、口底和下颌骨缺损修复中的临床实践。方法：应用肩胛区骨皮瓣游离移植修复因舌癌行扩大根治切除术后的舌、口底、下颌骨联合缺损病人2例,术中根据下颌骨、牙槽、口底和舌缺损的大小设计肩胛区骨皮瓣;术中顺向或逆向寻找血管蒂,掀起肩胛区骨皮瓣,游离移植于口内,吻合血管,固定肩胛骨瓣于颌骨缺损内,将皮瓣与口内缺损创缘缝合,覆盖牙槽、口底、再造舌。结果：骨皮瓣全部成活。患侧颌面形态和舌外形恢复满意。其中1例患者术后5天死亡,死因疑为消化道大出血。结论：肩胛区骨皮瓣具有血管恒定、切口隐蔽、对供区功能影响小、可供组织种类和组织量多、修复范围广等特点,是修复头颈部复合缺损的一种比较满意的方法。     

岛状鼻侧软骨粘膜瓣的解剖学研究及临床应用

目的：研究进入鼻侧软骨区域的主要血管,为设计内眦血管蒂岛状鼻侧软骨粘膜瓣修复眼睑衬里和睑板缺损提供解剖学基础,并介绍其临床应用经历。方法：10具存放一年的成年尸体标本从颈总动脉灌注红色乳胶,在2具尸体标本的面静脉内注入蓝色乳胶溶液。在3．5倍的手术放大镜下进行解剖,显露鼻背和鼻周区的血管。结果：内眦动脉发出分支从鼻侧软骨的外上方开始斜向其内下方向走行进入鼻侧软骨的表面,并与鼻背动脉和鼻外侧动脉向鼻侧软骨表面发出的分支相互吻合。并且内眦静脉与其伴行。应用岛状鼻侧软骨粘膜瓣修复下睑缺损1例,效果满意。结论：以内眦血管为蒂的岛状鼻侧软骨粘膜瓣具有良好的血液供应,血管蒂长并且走行比较恒定,可转移到眶区修复部分眼睑衬里和睑板缺损。     

腓肠神经营养血管远端蒂皮瓣修复足踝部软组织缺损

目的：总结应用腓肠神经营养血管远端蒂皮瓣修复足踝部皮肤软组织缺损的经验。方法：从2006年2月～2008年12月,笔者应用腓肠神经营养血管远端蒂皮瓣修复足踝部软组织缺损共12例,皮瓣最大15cm×10cm,最小6cm×5cm,筋膜蒂宽度为4～5cm,皮瓣旋转点至外踝尖距离5～7cm。皮瓣剥离的深度在腓肠肌肌膜深面,将小隐静脉和腓肠神经包含于内。蒂部均留有2cm宽度的皮肤,走明道向受区旋转。结果：12例皮瓣全部成活,无供血不足及静脉回流障碍。结论：腓肠神经营养血管远端蒂皮瓣血运丰富,制作简便,防止蒂部受压是成活率高的保证。