Marco J.P.F. Ritt

Hyperosmolarity and hypoxia induce chondrogenesis of adipose‐derived stem cells in a collagen type 2 hydrogel

Apart from soluble growth factors, various other biophysicochemical cues are known to promote chondrogenesis. Under physiological conditions, cartilage in the joint comprises a hyperosmotic and hypoxic environment. Therefore, in this study, we examined the inductive effects of hyperosmotic and/or hypoxic conditions on adipose stem cells (ASCs) and compared them with conventional TGFβ1‐induction. After encapsulation in collagen type II hydrogels and specific induction, ASCs were assessed for viability, proliferation, morphology and chondrogenic differentiation potential. Viability was similar under all conditions, with low proliferative activity. After 4 days, hypoxia and/or hyperosmolarity did not affect round cell morphology, while cells were mainly stretched in the TGFβ1‐induced group. At 21 days, the TGFß1‐treated group had aggregated into a cell nodule. Hyperosmolarity mimicked this aggregation to a lesser extent, whereas cells under hypoxia stretched out after 21 days, with a combined effect in the hypoxic/hyperosmotic group. Both individual and combined hyperosmotic and/or hypoxic conditions significantly upregulated SOX5, SOX9, COMP and Link‐p gene expression compared with the non‐induced group, and to similar levels as the TGFβ1‐induced group. GAG synthesis in both hydrogel and medium was increased under hypoxic conditions, whereas hyperosmolarity decreased GAG formation in the hydrogels, but increased GAG formation in the medium. We conclude that in a joint mimicking the three‐dimensional (3D) micro‐environment, a combination of hyperosmolarity and hypoxia is able to induce chondrogenesis to the same extent as TGFβ1. This might lead to an interesting alternative when considering short‐term triggering in a one‐step surgical procedure for the treatment of cartilaginous defects. Copyright

Two-stage implant-based breast reconstruction compared with immediate one-stage implant-based breast reconstruction augmented with an acellular dermal matrix: an open-label, phase 4, multicentre, randomised, controlled trial

BACKGROUND The evidence justifying the use of acellular dermal matrices (ADMs) in implant-based breast reconstruction (IBBR) is limited. We did a prospective randomised trial to compare the safety of IBBR with an ADM immediately after mastectomy with that of two-stage IBBR. METHODS We did an open-label, randomised, controlled trial in eight hospitals in the Netherlands. Eligible women were older than 18 years with breast carcinoma or a gene mutation linked with breast cancer who intended to undergo skin-sparing mastectomy and immediate IBBR. Randomisation was done electronically, stratified per centre and in blocks of ten to achieve roughly balanced groups. Women were assigned to undergo one-stage IBBR with ADM (Strattice, LifeCell, Branchburg, NJ, USA) or two-stage IBBR. The primary endpoint was quality of life and safety was assessed by the occurrence of adverse outcomes. Analyses were done per protocol with logistic regression and generalised estimating equations. This study is registered at Nederlands Trial Register, number NTR5446. FINDINGS 142 women were enrolled between April 14, 2013, and May 29, 2015, of whom 59 (91 breasts) in the one-stage IBBR with ADM group and 62 (92 breasts) in the two-stage IBBR group were included in analyses. One-stage IBBR with ADM was associated with significantly higher risk per breast of surgical complications (crude odds ratio 3·81, 95% CI 2·67-5·43, p<0·001), reoperation (3·38, 2·10-5·45, p<0·001), and removal of implant, ADM, or both (8·80, 8·24-9·40, p<0·001) than two-stage IBBR. Severe (grade 3) adverse events occurred in 26 (29%) of 91 breasts in the one-stage IBBR with ADM group and in five (5%) of 92 in the two-stage IBBR group. The frequency of mild to moderate adverse events was similar in the two groups. INTERPRETATION Immediate one-stage IBBR with ADM was associated with adverse events and should be considered very carefully. Understanding of selection of patients, risk factors, and surgical and postsurgical procedures needs to be improved. FUNDING Pink Ribbon, Nuts-Ohra, and LifeCell.

Hand and Wrist Malpractice Claims in the Netherlands: 1993-2008

We analysed hand and wrist injury and disorder related liability claims in the Netherlands to identify causes and to contribute to the prevention of such claims. Data was collected from 743 hand and wrist claims filed between 1993 and 2007. Consultants were involved in 417 claims (56.1%). Treatment in the emergency department (ED) accounted for 64.9% of these 287 claims involved residents (59.5%). The majority of accepted claims in the ED included treatment by general surgeons (89.2%). The percentage of accepted claims was highest in the general surgery group (26.4%). Of accepted claims in the ED which involved a resident, 93.2% involved a general surgery resident. Better training and supervision is indicated. This paper supports hand injury treatment by adequately trained surgeons and preferably, where possible, by a trained hand surgeon.

Revealing the impact of local access-site complications and upper extremity dysfunction post transradial percutaneous coronary procedures

ObjectivesLittle is known about local access-site complications and upper extremity dysfunction after transradial percutaneous coronary procedures (TR-PCP). This systematic review study aimed to summarise the current knowledge on the incidences of access-site complications and upper extremity dysfunction after TR-PCP.MethodsTwo independent, trained investigators searched MEDLINE, EMBASE and CENTRAL for eligible studies published before 1 January 2015. Also, they hand-searched the conference proceedings of the annual scientific sessions of the American College of Cardiology, the American Heart Association, European Society of Cardiology, and the Trans-catheter Cardiovascular Therapeutics. Inclusion criteria were cohort studies and clinical trials discussing the incidence of access-site complications and upper extremity function after transradial percutaneous coronary intervention (TR-PCI) and/or transradial coronary angiography (TR-CAG) as endpoints.Results176 articles described access-site complications. The incidence is up to 9.6 %. Fourteen articles described upper extremity dysfunction, with an incidence of up to 1.7 %. Upper extremity dysfunction was rarely investigated, hardly ever as primary endpoint, and if investigated not thoroughly enough.ConclusionUpper extremity dysfunction in TR-PCP has never been properly investigated and is therefore underestimated. Further studies are needed to investigate the magnitude, prevention and best treatment of upper extremity dysfunction. Optimising TR-PCP might be achieved by using slender techniques, detection of upper extremity dysfunction and early referral to a hand rehabilitation centre.

Results of latissimus dorsi transfer in obstetrical brachial plexus injury.

This study reports on 9 patients with obstetrical brachial plexus injury who underwent a latissimus dorsi (LD) transfer to reconstruct external rotation of the upper extremity. Transfer of the LD to the rotator cuff is widely used for restoring shoulder abduction and external rotation in patients with obstetrical brachial plexus injury. Patients were classified according to type of paralysis, age of surgery, and shoulder function. This retrospective article evaluated the results of the LD transfer in a group of 9 patients. The study shows that in the near future, profit can be made in active and passive external rotation.

Rationale and design of the ARCUS: Effects of trAnsRadial perCUtaneouS coronary intervention on upper extremity function

The aim of this study is to provide a complete insight in the access‐site morbidity and upper extremity function after Transradial Percutaneous Coronary Intervention (TR‐PCI).

The aesthetic items scale: A tool for the evaluation of aesthetic outcome after breast reconstruction

Background: Valid tools to assess aesthetic outcomes after breast reconstructive surgery are scarce. Previously a professional aesthetic assessment scale was introduced, the Aesthetic Items Scale (AIS). We aim to determine if this method is a valid and reliable tool to assess aesthetic outcome after breast reconstructive surgery. Methods: The study population was consenting women who underwent prophylactic mastectomy with subsequent implant-based breast reconstruction. The aesthetic outcome with regard to breast volume, shape, symmetry, scars, and nipple areola complex was rated on a 5-point scale using standardized photographs to give a summed total score. Photographs were evaluated by the patient, 5 plastic surgeons, and 3 mammography nurses. An overall rating of aesthetic outcome on a 1–10 scale was given separately. We determined the intraclass correlation coefficient and assessed interobserver agreement. To assess validity, we calculated the correlation between total score and overall rating of aesthetic outcome. Results: Interobserver reliability was highest between plastic surgeons for the subitem and overall scores and ranged between 0.56 and 0.82. The summed score of the AIS correlates strongly with the overall rating in professionals but not in patients. Conclusions: The AIS is a valid and reliable method for evaluating aesthetic outcome of breast reconstruction by plastic surgeons. The results indicate that patients judge aesthetic outcome differently, taking into account factors that are not represented in the AIS. Professionals can use this method to evaluate surgical results, but other measurements are needed to map satisfaction of the patient with her breasts.

Pronating radius osteotomy for supination deformity in children with obstetric brachial plexus palsy

Purpose: In obstetric brachial plexus lesions, muscle imbalance caused by active supinator muscles and paralyzed pronator muscles can result in a supination position of the wrist, which, apart from cosmesis, may interfere with function. Methods: In this retrospective study, we describe the results of a pronating radius osteotomy for supination deformity of the hand in children with an obstetric brachial plexus lesion. Results: After a mean follow-up of 23 months, all 8 patients (mean age, 9.4 years; range, 4-13 years), operated between 1998 and 2006, had improved functionally and aesthetically. Conclusions: All patients had improved functionally and aesthetically.

Predictors of complications after direct-to-implant breast reconstruction with an acellular dermal matrix from a multicentre randomized clinical trial: Complications after direct-to-implant breast reconstruction with an acellular dermal matrix

In the multicentre randomized trial BRIOS (Breast Reconstruction In One Stage), direct‐to‐implant (DTI) breast reconstruction with an acellular dermal matrix (ADM) was associated with a markedly higher postoperative complication rate compared with two‐stage tissue expander/implant breast reconstruction. This study aimed to identify factors that contribute to the occurrence of complications after DTI ADM‐assisted breast reconstruction.

The aetiopathogenesis of capsular contracture: A systematic review of the literature

BACKGROUND Capsular contracture is the most frequent complication after breast augmentation or reconstruction with breast implants. The immune system plays a prominent role in capsular contracture formation, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for capsular contracture. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of capsular contracture. MATERIALS AND METHODS We undertook a systematic literature review focused on immunological factors and microbiota in relation to capsular contraction around implants. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE, and the Cochrane databases were searched from inception up to October 2016. Included studies were assessed for the following variables: subject characteristics, number of capsules, primary indication for surgery, surgical procedure, follow-up or implant duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors. RESULTS Data on immunological factors and bacterial contamination were retrieved from 64 included studies. Notably the presence of macrophages and Staphylococcus epidermidis within capsules was often associated with capsular contracture. CONCLUSION This review provides a clear overview of the immunological factors associated with capsular contracture and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with capsular contracture has been provided. Follow-up research may result in clinical recommendations to prevent capsular contracture.