[Clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury]

Objective: To investigate the clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury. Methods: The study was a retrospective observational study. From May 2019 to January 2022, 11 patients with upper limb complex tissue defects combined with main artery injury who met the inclusion criteria were admitted to the Department of Hand, Foot and Ankle Surgery of General Hospital of Ningxia Medical University, including 7 males and 4 females, aged from 18 to 56 years. After debridement, the area of skin and soft tissue defects was from 20 cm×6 cm to 32 cm×10 cm, and the exposed area of dead cavity or deep tissue was from 7 cm×4 cm to 10 cm×7 cm. Three patients had radial artery defects with a length of 4 to 7 cm; two patients had ulnar artery defects with a length of 5 to 8 cm; 4 patients had defects in both ulnar and radial arteries with a length of 3 to 7 cm; and in two patients, the ulnar, radial and brachial arteries were all defective with a length of 4 to 8 cm. The anterolateral thigh flow-through chimeric perforator flap was designed and cut. The skin flap area was from 22 cm×7 cm to 32 cm×11 cm, the chimeric muscle flap area was from 7 cm×4 cm to 10 cm×7 cm, and the length of the flow-through vessel in the "T" shaped vessel pedicle was from 4 to 8 cm. When transplanting the skin flap, the proximal end of the vascular pedicle was anastomosed with the proximal end of the recipient site, and the distal end of the vascular pedicle was anastomosed with the more normal blood vessel at the distal end of the forearm; the invalid cavity was filled with the muscle flap. The donor site wounds of tissue flap were closed directly or treated with skin grafting. After operation, the blood supply and survival of the flap, the survival of the distal limb, and the survival of the skin graft at the flap donor site were observed. Computed tomography angiography (CTA) was performed to observe the patency of the proximal and distal anastomotic arteries from 2 to 4 weeks after surgery. During follow-up, the texture of the flap, the survival of the grafted skin and the healing of the donor area were observed. Results: One patient (complete forearm disconnection) developed distal limb blood disorder on 5 days after surgery. CTA examination suggested embolization of the distal anastomosis of the flow-through artery. more muscle and skin and soft tissue necrosis of the distal limb showed in emergency exploration. So, amputation was performed ultimately. No vascular crisis occurred in the skin flaps of the remaining 10 patients, and all skin flaps, distal limbs and the skin grafts in flap donor sites survived well. Two to 4 weeks after surgery, the proximal and distal ends of the anastomosed arteries were good in the patency. Follow-up for 11-37 months, the flap texture was good, and all donor site wounds healed well. Conclusions: The use of anterolateral thigh flow-through chimeric perforator flap to repair upper limb complex tissue defects accompanied by main artery injury can improve the success rate of limb salvage, which can be promoted in clinical practice.

[Diagnosis and treatment strategies of 56 cases of middle ear myoclonus]

Objective: To analyze the clinical characteristics and treatment of middle ear myoclonus. Methods: Fifty-six cases of middle ear myoclonus were enrolled in Shandong Provincial ENT Hospital, Shandong University from September 2019 to August 2021, including 23 males and 33 females. The age ranged from 6 to 75 years, with a median age of 35 years; Forty-seven cases were unilateral tinnitus, nine cases were bilateral tinnitus. The time of tinnitus ranged from 20 days to 8 years. The voice characteristics, inducing factors, nature (frequency) of tinnitus, tympanic membrane conditions during tinnitus, audiological related tests, including long-term acoustic tympanogram, stapedius acoustic reflex, pure tone auditory threshold, short increment sensitivity test, alternate binaural loudness balance test, loudness discomfort threshold, vestibular function examination, facial electromyography, and imaging examination were recorded. Oral carbamazepine and/or surgical treatment were used. The patients were followed up for 6-24 months and the tinnitus changes were observed. Results: Tinnitus was diverse, including stepping on snow liking sound, rhythmic drumming, white noise, and so on. The inducing factors included external sound, body position change, touching the skin around the face and ears, speaking, chewing and blinking, etc. Forty-four cases were induced by single factor and 9 cases were induced by two or more factors. There was no definite inducing factor in 1 case. One patient had tinnitus with epilepsy. One case of traumatic facial paralysis after facial nerve decompression could induce tinnitus on the affected side when the auricle moved. Tympanic membrane flutter with the same frequency as tinnitus was found in 12 cases by otoscopy, and the waveform with the same frequency as tinnitus was found by long-term tympanogram examination. There were 7 patients with no tympanic membrane activity by otoscopy, the 7 cases also with the same frequency of tinnitus by long-term tympanogram examination, but the change rate of the waveform was faster than that of the patients with tympanic membrane flutter. All patients with tinnitus had no change in hearing. One case of tinnitus complicated with epilepsy (a 6-year-old child) was treated with antiepileptic drug (topiramate) and tinnitus subsided. One case suffered from tinnitus after facial nerve decompression for traumatic facial paralysis was not given special treatment. Fifty-four cases were treated with oral drug (carbamazepine), of which 10 cases were completely controlled and 23 cases were relieved; 21 cases were invalid. Among the 21 patients with no effect of carbamazepine treatment, 8 patients were treated by surgery, 7 patients had no tinnitus after surgery, 1 patient received three times of operation, and the third operation was followed up for 6 months, no tinnitus occurred again. The other 13 cases refused the surgical treatment due to personal reasons. Conclusions: Middle ear myoclonus tinnitus and the inducing factors manifestate diversity. Oral carbamazepine and other sedative drugs are effective for some patients, and surgical treatment is feasible for those who are ineffective for medication.

[Fabrication of tissue engineered skin equivalent]

OBJECTIVE

To fabricate artificial human skin with the tissue engineering methods.

METHODS

The artificial epidermis and dermis were fabricated based on the successful achievements of culturing human keratinocytes(Kc) and fibroblasts (Fb) as well as fabrication of collagen lattice. It included: 1. Culture of epidermal keratinocytes and dermal fibroblasts: Kc isolated from adult foreskin by digestion of trypsin-dispase. Followed by comparison from aspects of proliferation, differentiation of the Kc, overgrowth of Fb and cost-benefits. 2. Fabrication of extracellular matrix sponge: collagen was extracted from skin by limited pepsin digestion, purified with primary and step salt fraction, and identified by SDS-PAGE. The matrix lattice was fabricated by freeze-dryer and cross-linked with glutaraldehyde, in which the collagen appeared white, fibrous, connected and formed pores with average dimension of 180 to 260 microns. 3. Fabrication artificial human skin: The artificial skin was fabricated by plating subcultured Kc and Fb separately into the lattice with certain cell density, cultured for one week or so under culture medium, then changed to air-liquid interface, and cultured for intervals.

RESULTS

The artificial skin was composed of dermis and epidermis under light microscope. Epidermis of the skin consisted of Kc at various proliferation and differentiation stages, which proliferated and differentiated into basal cell layer, prickle cell layer, granular layer, and cornified layer. Conifilament not only increased in number, but also gathered into bundles. Keratohyalin granules at different development stages increased and became typical. The kinetic process of biochemistry of the skin was coincide with the changes on morphology.

CONCLUSION

Tissue engineered skin equivalent has potential prospects in application of repairing skin defect with advantages of safe, effective and practical alternatives.

Bone bonding in bioactive glass ceramics combined with bone matrix gelatin

To determine how to encourage inductive osteogenesis on bioactive ceramics and accelerate the bonding of implants to the surrounding bone, we studied the role of autolyzed antigen-extracted allogeneic bone gelatin (AAAG) in bone bonding to bioactive ceramic implants in rabbit tibiae. Smooth-surfaced plates (15 x 10 x 2 mm) of apatite and wollastonite containing glass-ceramic were implanted into the proximal metaphyses of tibiae, with AAAG packed into the medullary cavity in one limb but not in the contralateral limb, which served as a paired control. After 2, 4, 8, 16, and 25 weeks, bone bonding and bone formation at the bone/implant interfaces were evaluated by a detaching test and undecalcified histological examination. The tensile failure load increased from 2 to 25 weeks for both groups. The failure load of the AAAG-treated group was significantly greater than that of the control group at every stage. Histologically, the AAAG-treated specimens showed active new bone formation in the medullary cavity and extensive bonding between the implant and bone at early periods. The percentage of bony covering in the AAAG-treated group was significantly higher than that of the controls at all intervals except at 25 weeks. The results of this study suggest that the addition of osteoinductive AAAG to a bioactive implant may significantly accelerate bone apposition to the implant and improve the bonding process at the interface, which would help to establish an earlier and stronger bonding between the implants and the surrounding bone.

Bone bonding in bioactive glass ceramics combined with bone matrix gelatin

To determine how to encourage inductive osteogenesis on bioactive ceramics and accelerate the bonding of implants to the surrounding bone, we studied the role of autolyzed antigen-extracted allogeneic bone gelatin (AAAG) in bone bonding to bioactive ceramic implants in rabbit tibiae. Smooth-surfaced plates (15 x 10 x 2 mm) of apatite and wollastonite containing glass-ceramic were implanted into the proximal metaphyses of tibiae, with AAAG packed into the medullary cavity in one limb but not in the contralateral limb, which served as a paired control. After 2, 4, 8, 16, and 25 weeks, bone bonding and bone formation at the bone/implant interfaces were evaluated by a detaching test and undecalcified histological examination. The tensile failure load increased from 2 to 25 weeks for both groups. The failure load of the AAAG-treated group was significantly greater than that of the control group at every stage. Histologically, the AAAG-treated specimens showed active new bone formation in the medullary cavity and extensive bonding between the implant and bone at early periods. The percentage of bony covering in the AAAG-treated group was significantly higher than that of the controls at all intervals except at 25 weeks. The results of this study suggest that the addition of osteoinductive AAAG to a bioactive implant may significantly accelerate bone apposition to the implant and improve the bonding process at the interface, which would help to establish an earlier and stronger bonding between the implants and the surrounding bone.

Bonding of chemically treated titanium implants to bone

A study was undertaken in rabbit tibiae to determine the effects of chemical treatments and/or surface-induced bonelike apatite on the bone-bonding ability of titanium (Ti) implants. Smooth-surfaced plates (10 x 10 x 2 mm) of pure Ti, alkalil- and heat-treated Ti, and bonelike apatite-formed Ti after the treatments were implanted into the tibial metaphyses of mature rabbits. The tibiae containing the implants were harvested at 4, 8, and 16 weeks after implantation and subjected to a tensile testing and histologic evaluation. Biomechanical results showed that both treated implants exhibited significantly higher failure loads compared with untreated Ti implants at all time periods. Histologic examination by Giemsa surface staining, contact microradiography (CMR), and scanning electron microscopy (SEM) in backscatter mode revealed that both treated Ti implants directly bonded to bone tissue during the early postimplantation period, whereas untreated Ti implants formed direct contact with the bone only at 16 weeks. SEM-electron-probe microanalysis (EPMA) examination showed a Ca-P-rich layer at the interface between the treated implants and bone, although the Ca-P-rich layer was not detected on the surface of untreated implants during observation periods. The results of this study suggest that chemical treatments may accelerate the bone-bonding behavior of titanium implants and enhance the strength of bone-implant bonding by inducing a bioactive surface layer on Ti implants.

Apatite layer-coated titanium for use as bone bonding implants

For development of thin bioactive coatings on metal implants, a dense and uniform apatite layer was coated onto titanium (Ti) implants in situ by using a new biomimetic method, which is composed of apatite nucleation and growth steps in simulated body fluid (SBF). Analysis of the coatings by thin film X-ray diffraction and scanning electron microscopy-energy dispersive X-ray microanalysis (SEM-EMPA) before implantation showed that its characteristics were very similar to those of natural bone. The coated and uncoated rectangular plates were bilaterally implanted into the tibial proximal metaphyses of rabbits. After 6, 10 and 25 weeks post-implantation, the bone bonding and bone formation at the bone-implant interfaces were evaluated by a detachment test and undecalcified histological examination. Mechanical testing in tension showed that the failure load of apatite layer-coated Ti implants was significantly higher than that of uncoated control at each time period (all P < 0.001). Histologically, it was shown that bone was deposited directly onto the apatite coating without any intervening soft tissue, while in the paired controls, interpositional soft tissue was seen at the bone-implant interface. By SEM-EPMA, a uniform calcium- and phosphorus-rich layer was detected between the coated implants and bone, but not in uncoated controls at either earlier or later time periods. The results indicate that the apatite layer deposited on Ti in situ may significantly increase the bone bonding strength by providing a bioactive surface, which allows for an early bone apposition to the implant. In addition, the apatite layer-coated Ti produced by the biomimetic process may fulfil the requirements of favourable thin coatings and strong adhesion at the metal-coating interface.

Bone bonding behavior of titanium and its alloys when coated with titanium oxide (TiO2) and titanium silicate (Ti5Si3)

It has been proposed that the essential requirement for artificial materials to bond to living bone is the formation of bonelike apatite on their surfaces in the body. Recent studies have shown that titanium hydrogel and silica gel induce apatite formation on their surface in a simulated body fluid. In this study, the influence of titanium oxide and titanium silicate on the bonding of titanium alloys to bone was studied. Rectangular implants (15 x 10 x 2.2 mm) of titanium, Ti-6Al-4V, Ti-6Al-2Nb-Ta, Ti-6Al-4V coated with TiO2, and Ti-6Al-4V coated with Ti5Si3 were implanted into the tibial metaphyses of mature rabbits. At 8 and 24 weeks after implantation, the tibiae containing the implants were dissected out and subjected to a detaching testing. The failure load for titanium, Ti-6Al-4V, Ti-6Al-2Nb-Ta, Ti-6Al-4V coated with TiO2, and Ti-6Al-4V coated with Ti5Si3 were, respectively, 0.68 +/- 0.48, 0.22 +/- 0.46, 0.67 +/- 0.59, 2.18 +/- 0.71 and 2.03 +/- 0.41 kgf at 8 weeks, and 2.7 +/- 0.91, 2.58 +/- 1.29, 2.38 +/- 0.41, 3.79 +/- 1.7, and 2.79 +/- 0.87 kgf at 24 weeks after implantation. Histological examination by Giemsa surface staining, CMR, and SEM-EPMA revealed the coated titanium alloy implants directly bonded to bone tissue during early implantation. A Ca-P layer was observed at the interface of the coated implants and the bone. The results of this study indicated that TiO2 and Ti5Si3 can enhance the early bonding of titanium alloys to bone by inducing a Ca-P layer (chemical apatite) on the surface of titanium alloys. It also is suggested that the direct bone contact occurs in relation to the calcium and phosphorus adsorption onto the surface of the titanium passive layer formed during long-term implantation.

[Stimulation of maturing and terminal differentiation by concanavalin A in rabbit permanent chondrocyte cultures]

The effect of concanavalin A (Con A) on maturing and terminal differentiation in permanent chondrocyte cultures were examined. Chondrocytes isolated from permanent cartilage were seeded at low density and grown in MEM medium containing 10% fetal bovine serum, 50 micrograms/ml of ascorbic acid and antibiotics, at 37 degrees C under 50% CO2 in air. At 0.3% of low serum concentration, addition of Con A to the culture medium increased by 3- to 4-fold the incorporation of [35S] sulfate into large chondroitin sulfate proteoglycan that characteristically found in cartilage. Chemical analysis showed a 4-fold increase in the accumulation of macromolecular containing hexuronic acid in Con A-maintained cultures. The effect of Con A on [35S]sulfate incorporation into proteoglycan was greater than that of various growth factor or hormones. Brief exposure of the permanent chondrocytes to Con A (5 micrograms/ml) for 24 hours and subsequent incubation in its absence for 5-10 days resulted in 10- to 100-fold increase in alkaline phosphatase and binding of 1.25 (OH)2 vitamin D3 to cells. Treatment with Con A also resulted in 10- to 20-fold increase in calcium content and 45Ca incorporation into insoluble material. Methyl-D-mannopyranoside reversed the effect of Con A on [35S]sulfate incorporation into proteoglycan and alkaline phosphatase activity. Since other lectins, such as wheat germ agglutinin, lentil lectin, phytohemagglutinin, Ulex europeasu agglutinin and garden pea lectin had been tested to have little effect on [35S]sulfate incorporation into proteoglycans and induction of alkaline phosphatase activity, the Con A action on chondrocytes seems specific. These results indicate that Con A is a potent modulator of differentiation of chondrocytes, which induces the onset on a maturing and a terminal differentiation in chondrocytes, leading to extensive calcification of the extracellular matrix.

[Effect of concanavalin A on morphology and DNA synthesis of resting chondrocyte cultures]

Rabbit chondrocytes were isolated from resting cartilage of ribs of 4-week-old New Zealand rabbits. Chondrocytes were seeded at low density and grown to confluency in medium (DME) with 10% fetal bovine serum, 50 micrograms/ml ascorbic acid, and antibiotics, at 37 degrees C under 5% CO2 in air, and then serum concentration was reduced to 0.3%. At the low serum concentration, chondrocytes adopted fibroblastic morphology. Addition of concanavalin A to the culture medium induced a morphologic alteration of the fibroblastic cells to polygonal or spherical chondrocytes that were surrounded by refractile matrix. Wheat germ agglutinin and garden pea lectin induced similar cell shape changes without any increase in matrix synthesis. Concanavalin A decreased [3H]thymidine incorporation into DNA in a dose-dependent manner with an ED50 of 0.4-1 micrograms/ml in the presence of various concentrations of serum ranging from 0.3 to 20%. The concanavalin A inhibition of DNA synthesis was abolished by 10 mmol/L methyl-D-mannopyranoside. The inhibition of chondrocyte proliferation does not seem to be specific to concanavalin A. Wheat germ agglutinin, lentil lectin, phytohemagglutinin, Ulex europeaus agglutinin, and garden pea lectin also decreased, dose-dependently, [3H]thymidine incorporation into DNA in chondrocytes. Other lectins at 0.01-20 micrograms/ml had little effect on [3H] thymidine incorporation. Because the molecular structure of concanavalin A and its mode of actions have been extensively characterized, chondrocytes exposed to this lectin will be useful as a novel model in studying of the control of cellular differentiation.

[Reorganization of growth-plate-like tissue by isolated chondrocytes in culture]

Growth-plate cartilage is organized into four cellular zones containing resting, proliferating, maturing, and hypertrophic cells. Rabbit chondrocytes were isolated from growth-plate costal cartilage of 4-week-old New Zealand rabbits, the cells (15 x 10(4)) were suspended in 1 ml of Iscove's modified Dulbecco's medium (IMDM) with 10% fetal bovine serum, 50 micrograms ascorbic acid, and 60 micrograms kanamycin (medium A), then transferred to a 15 ml of plastic centrifuge tube, and centrifuged at 1500 rpm for 5 min. The cell pellet was incubated at 37 degrees C under 5% CO2 in air. The cultures reorganized into growth plate-like tissue which could be seen 7-14 days after cell seeding. This growth-plate, histologically, was organized longitudinally into cellular columns and horizontally into four cellular zones containing resting, proliferating, maturing and hypertrophic cells. The hypertrophic cells in the upper were large in size and round or oval in shape, the proliferating and the mature chondrocytes in the lower were small in size and spherical or elongated in shape. These chondrocytes were surrounded by an extensive matrix. Biochemically, DNA content of cultures began to rise on the 2nd day after cell seeding and reached a plateau after 10 days later. The uronic acid content increased from day 4 and reached the maximum on day 15. In contrast in the early culture, alkaline phosphatase activity was extremely low, it began to rise on day 9 and was the highest on day 20. The sequential increase of DNA, uronic acid and alkaline phosphatase contents was analogous to the in vivo changes of growth-plate chondrocytes.

Stimulation by concanavalin A of cartilage-matrix proteoglycan synthesis in chondrocyte cultures

The effect of concanavalin A on proteoglycan synthesis by rabbit costal and articular chondrocytes was examined. Chondrocytes were seeded at low density and grown to confluency in medium supplemented with 10% fetal bovine serum, and then the serum concentration was reduced to 0.3%. At the low serum concentration, chondrocytes adopted a fibroblastic morphology. Addition of concanavalin A to the culture medium induced a morphologic alteration of the fibroblastic cells to spherical chondrocytes and increased by 3- to 4-fold incorporation of [35S]sulfate and [3H]glucosamine into large chondroitin sulfate proteoglycan that was characteristically found in cartilage. The stimulation of incorporation of labeled precursors reflected real increases in proteoglycan synthesis, as chemical analyses showed a 4-fold increase in the accumulation of macromolecules containing hexuronic acid in concanavalin A-maintained cultures. Furthermore, the effect of concanavalin A on [35S]sulfate incorporation into proteoglycans was greater than that of various growth factors or hormones. However, concanavalin A had smaller effects on [35S]sulfate incorporation into small proteoglycans and [3H]glucosamine incorporation into hyaluronic acid and chondroitinase AC-resistant glycosaminoglycans. Since other lectins tested, such as wheat germ agglutinin, lentil lectin, and phytohemagglutinin, had little effect on [35S]sulfate incorporation into proteoglycans, the concanavalin A action on chondrocytes seems specific. Although concanavalin A decreased [3H]thymidine incorporation in chondrocytes, the stimulation of proteoglycan synthesis could be observed in chondrocytes exposed to the inhibitor of DNA synthesis, cytosine arabinoside. These results indicate that concanavalin A is a potent modulator of proteoglycan synthesis by chondrocytes.

The endocrinological profile of normal menstrual cycles in a population of Chinese women

Endocrinological profiles of normal menstrual cycles were studied in 41 Chinese women. Daily serum concentration of luteinizing hormone (LH), follicle stimulating hormone (FSH), prolactin (PRL), estradiol (E2) and progesterone (P) were determined by RIA. Thirty-four cycles were of normal length (26-35 days) and 6 cycles were prolonged up to 40 days with a follicular phase of 22-26 days. One cycle was anovulatory. Cyclical changes of LH, FSH, E2 and P were typical of ovulatory cycles in other populations as reported in the literature. In the normal cycle group the geometric mean of the LH midcycle peak level was 46 IU/1, the FSH peak was 10 IU/1, the preovulatory estradiol peak was 1229 pmol/1 and the progesterone luteal maximum was 50 nmol/1. The pattern of cyclical changes in the prolonged ovulatory cycles was similar to the normal length cycles, except that there were significantly higher levels of LH in both follicular and luteal phases, lower FSH in luteal phase, and lower progesterone in luteal phase. A majority of cycles had a midcycle elevation of prolactin and mean PRL levels in the late luteal phase were higher than those in the follicular phase.