Paul M. N. Werker

Complications of abdominoplasty in 86 patients

A total of 101 consecutive abdominoplasty patients were reviewed retrospectively. Of these, 14 male (mean age at time of operation, 34.3 years; range, 23 to 53 years) and 72 female (mean age at time of operation, 38.9 years; range, 19 to 64 years) patients had adequate documentation for inclusion in this study. Complications were recorded as either wound complications (wound infection, partial wound dehiscence, seroma, hematoma, and skin edge necrosis) or complications after surgery (deep vein thrombosis, pulmonary emboli, ileus, sensibility disorder of the skin of the thighs, and death). The complications were subsequently correlated for sex, race, the patients age at surgery, body mass index before surgery, and the seniority of the surgeon. Nine male patients (64.3 percent) and 11 female patients (15.3 percent) had wound complications. Almost 10 percent of our patients sustained an injury to the lateral cutaneous nerve of the thigh. Male patients should be informed about their possible higher risk of complications, and special attention must be given by the surgeon to the prevention of such complications.Moreover, specific attention must be given to the preservation of the lateral cutaneous nerves of the thigh in both male and female patients undergoing abdominoplasties.

Five-year results of a randomized clinical trial on treatment in Dupuytren's disease: percutaneous needle fasciotomy versus limited fasciectomy.

Background: The increasing number of methods for treating Dupuytrens disease indicates a need for comparative studies. In this article, the 5-year follow-up results of a randomized controlled study that compared percutaneous needle fasciotomy and limited fasciectomy are presented. Methods: One hundred eleven patients with 115 affected hands with a minimal passive extension deficit of 30 degrees were assigned randomly to the two groups. Follow-up examinations were performed at 1 and 6 weeks; 6 months; and 1, 2, 3, 4, and 5 years. Outcome parameters were total passive extension deficit, patient satisfaction, flexion, and sensibility. Furthermore, disease extension was recorded. The primary endpoint was recurrence, defined as an increase of total passive extension deficit of greater than 30 degrees. Ninety-three patients reached this endpoint. Results: The recurrence rate after 5 years in the needle fasciotomy group (84.9 percent) was significantly higher than in the limited fasciectomy group (20.9 percent) (p < 0.001), and occurred significantly sooner in the needle fasciotomy group (p = 0.001). Older age at the time of treatment decreased the recurrence rate (p = 0.005). No other diathesis characteristics influenced recurrence. Patient satisfaction was high in both groups but was significantly higher in the limited fasciectomy group. Nevertheless, many patients (53 percent) preferred percutaneous needle fasciotomy in case of recurrence. Conclusions: Percutaneous needle fasciotomy is the preferred treatment for elderly patients with Dupuytrens disease and for those willing to accept a possible early recurrence in the context of the advantages, such as fast recovery, a low complication rate, and minimal invasiveness. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Advancements in Free Flap Monitoring in the Last Decade : A Critical Review

Background: The authors conducted a review of the recent literature on the monitoring of free flaps to create an overview of the current monitoring devices and their potential as an ideal monitoring method. Methods: A literature-based study was conducted using the PubMed and Cochrane databases. The following search terms were used: “flap” and “monitoring.” All monitoring methods found between January of 1999 and January of 2009 were evaluated. Monitoring methods that were described in five or more clinical reports were further investigated. Results: The advantages and disadvantages of conventional monitoring methods, the implantable Doppler system, color duplex sonography, near-infrared spectroscopy, microdialysis, and laser Doppler flowmetry are presented. Furthermore, an overview is given of their potential as ideal monitoring method. Conclusions: The implantable Doppler system, near-infrared spectroscopy, and laser Doppler flowmetry appear to be the best monitoring devices currently available. As most of the publications on monitoring have focused on the reliability of the systems, future research should also address their cost efficiency.

Wnt Signaling and Dupuytren's Disease

BACKGROUND Dupuytrens disease is a benign fibromatosis of the hands and fingers that leads to flexion contractures. We hypothesized that multiple genetic and environmental factors influence susceptibility to this disease and sought to identify susceptibility genes to better understand its pathogenesis. METHODS We conducted a genomewide association study of 960 Dutch persons with Dupuytrens disease and 3117 controls (the discovery set) to test for association between the disease and genetic markers. We tested the 35 single-nucleotide polymorphisms (SNPs) most strongly associated with Dupuytrens disease (P<1×10(-4)) in the discovery set in three additional, independent case series comprising a total of 1365 affected persons and 8445 controls from Germany, the United Kingdom, and The Netherlands. RESULTS Initially, we observed a significant genomewide association between Dupuytrens disease and 8 SNPs at three loci. Tests of replication and joint analysis of all data from 2325 patients with Dupuytrens disease and 11,562 controls yielded an association with 11 SNPs from nine different loci (P<5.0×10(-8)). Six of these loci contain genes known to be involved in the Wnt-signaling pathway: WNT4 (rs7524102) (P=2.8×10(-9); odds ratio, 1.28), SFRP4 (rs16879765) (P=5.6×10(-39); odds ratio, 1.98), WNT2 (rs4730775) (P=3.0×10(-8); odds ratio, 0.83), RSPO2 (rs611744) (P=7.9×10(-15); odds ratio, 0.75), SULF1 (rs2912522) (P=2.0×10(-13); odds ratio, 0.72), and WNT7B (rs6519955) (P=3.2×10(-33); odds ratio, 1.54). CONCLUSIONS This study implicates nine different loci involved in genetic susceptibility to Dupuytrens disease. The fact that six of these nine loci harbor genes encoding proteins in the Wnt-signaling pathway suggests that aberrations in this pathway are key to the process of fibromatosis in Dupuytrens disease.

Current opportunities and challenges in skeletal muscle tissue engineering

The purpose of this article is to give a concise review of the current state of the art in tissue engineering (TE) of skeletal muscle and the opportunities and challenges for future clinical applicability. The endogenous progenitor cells of skeletal muscle, i.e. satellite cells, show a high proneness to muscular differentiation, in particular exhibiting the same characteristics and function as its donor muscle. This suggests that it is important to use an appropriate progenitor cell, especially in TE facial muscles, which have a exceptional anatomical and fibre composition compared to other skeletal muscle. Muscle TE requires an instructive scaffold for structural support and to regulate the proliferation and differentiation of muscle progenitor cells. Current literature suggests that optimal scaffolding could comprise of a fibrin gel and cultured monolayers of muscle satellite cells obtained through the cell sheet technique. Tissue‐engineered muscle constructs require an adequate connection to the vascular system for efficient transport of oxygen, carbon dioxide, nutrients and waste products. Finally, functional and clinically applicable muscle constructs depend on adequate neuromuscular junctions with neural cells. To reach this, it seems important to apply optimal electrical, chemotropic and mechanical stimulation during engineering and discover other factors that influence its formation. Thus, in addition to approaches for myogenesis, we discuss the current status of strategies for angiogenesis and neurogenesis of TE muscle constructs and the significance for future clinical use. Copyright

The long-term durability of plication of the anterior rectus sheath assessed by ultrasonography

The purpose of this study was to assess the long-term durability of a standard vertical plication of the anterior rectus sheath. For this purpose, 70 women who had undergone this procedure as part of an abdominoplasty were sent a questionnaire, their records were studied, and they were invited back to the clinic for an examination using ultrasound. A total of 63 patients returned the questionnaire, and 40 were willing to attend a follow-up consultation and ultrasound investigation. The presence of rectus diastasis was assessed by ultrasound (a real time scanner with a 7.5-MHz linear probe). The study showed that after a follow-up of 32 to 109 months (mean, 64 months), standard plication of the abdominal wall with absorbable material led to residual or recurrent diastasis in 40 percent of the patients. It also confirmed that vertical plication only is not enough to improve the waistline and may eventually lead to epigastric bulging.

A systematic review and meta-analysis on the prevalence of Dupuytren disease in the general population of Western countries

Background: Dupuytren disease is a fibroproliferative disease of palmar fascia of the hand. Its prevalence has been the subject of several reviews; however, an accurate description of the prevalence range in the general population—and of the relation between age and disease—is lacking. Methods: Embase and PubMed were searched using database-specific Medical Subject Headings; titles and abstracts were searched for the words “Dupuytren,” “incidence,” and “prevalence.” Two reviewers independently assessed the articles using inclusion and exclusion criteria, and rated the included studies with a quality assessment instrument. In a meta-analysis, the median prevalence, as a function of age by sex, was estimated, accompanied by 95 percent prediction intervals. The observed heterogeneity in prevalence was investigated with respect to study quality and geographic location. Results: Twenty-three of 199 unique identified articles were included. The number of participants ranged from 37 to 97,537, and age ranged from 18 to 100 years. Prevalence varied from 0.6 to 31.6 percent. The quality of studies differed but could not explain the heterogeneity among studies. Mean prevalence was estimated as 12, 21, and 29 percent at ages 55, 65, and 75 years, respectively, based on the relation between age and prevalence determined from 10 studies. Conclusions: The authors describe a prevalence range of Dupuytren disease in the general population of Western countries. The relation between age and prevalence of Dupuytren disease is given according to sex, including 95 percent prediction intervals. It is possible to determine disease prevalence at a certain age for the total population, and for men and women separately.

Prevalence of Dupuytren disease in The Netherlands

Background: Dupuytren disease is a fibroproliferative disease of palmar fascias of the hand. The prevalence of Dupuytren disease and the association with potential risk factors have been the subject of several studies, although there is a paucity of such data from The Netherlands. Methods: To study the prevalence of Dupuytren disease, the authors drew a random sample of 1360 individuals, stratified by age, from the northern part of The Netherlands. Of this sample, 763 individuals aged 50 to 89 years participated in this cross-sectional study. The authors examined both hands for signs of Dupuytren disease, and a questionnaire was conducted to identify potential risk factors. The effects of these risk factors were investigated using logistic regression analysis. Additional analyses were performed to develop a logistic prediction model for the prevalence of Dupuytren disease. Results: The prevalence of Dupuytren disease was 22.1 percent. Nodules and cords were seen in 17.9 percent, and flexion contractures were present in 4.2 percent of the study population. Prevalence increased with age, from 4.9 percent in participants aged 50 to 55 years to 52.6 percent among those aged 76 to 80 years. Men were more often affected than women; 26.4 percent versus 18.6 percent, respectively (p = 0.007). Other significant risk factors were previous hand injury, excessive alcohol consumption, familial occurrence of Dupuytren disease, and presence of Ledderhose disease. Conclusions: The results show a high prevalence of Dupuytren disease in The Netherlands, particularly the nodular form. Using the developed logistic prediction model, the prevalence of Dupuytren disease can be estimated, based on the presence of significant risk factors. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Introduction of the Implantable Doppler System Did Not Lead to an Increased Salvage Rate of Compromised Flaps: A Multivariate Analysis

Background: The Cook-Swartz implantable Doppler system was introduced at the Uppsala University Hospital to ease free flap monitoring and improve salvage rates by an earlier detection of vascular compromise. The aim of the current analysis was to investigate whether the system indeed improved the salvage rate of revisions. Methods: All cases that needed revision among a consecutive series of patients being monitored with the implantable Doppler system between June of 2006 and January of 2009 were compared with a similar set of patients operated on before the introduction of the implantable Doppler system over an equal time span monitored with conventional methods. Data were extracted from the medical files of the patients. Logistic regression was used to identify factors associated with the outcome of the revision. Values of p < 0.05 were considered statistically significant. Results: A total of 327 flaps were monitored with the implantable Doppler system, of which 35 needed revision. In the control group, 303 flaps were included, of which 40 needed revision. The revision was successful in 69 percent of the cases in the implantable Doppler system group; in the group monitored by only conventional methods, this rate was 60 percent. Univariate analysis showed no statistical difference between these success rates (p = 0.441; odds ratio, 1.455; 95 percent confidence interval, 0.560 to 3.775). Multivariate analysis did not show a statistical difference either (p = 0.799; odds ratio, 1.143; 95 percent confidence interval, 0.410 to 3.182). Conclusion: The introduction of the implantable Doppler system did not lead to a significant increase in the salvage rate of revised flaps.

Hypoxia promotes proliferation of human myogenic satellite cells: a potential benefactor in tissue engineering of skeletal muscle.

Facial paralysis is a physically, psychologically, and socially disabling condition. Innovative treatment strategies based on regenerative medicine, in particular tissue engineering of skeletal muscle, are promising for treatment of patients with facial paralysis. The natural source for tissue-engineered muscle would be muscle stem cells, that is, human satellite cells (SC). In vivo, SC respond to hypoxic, ischemic muscle damage by activation, proliferation, differentiation to myotubes, and maturation to muscle fibers, while maintaining their reserve pool of SC. Therefore, our hypothesis is that hypoxia improves proliferation and differentiation of SC. During tissue engineering, a three-dimensional construct, or implanting SC in vivo, SC will encounter hypoxic environments. Thus, we set out to test our hypothesis on SC in vitro. During the first five passages, hypoxically cultured SC proliferated faster than their counterparts under normoxia. Moreover, also at higher passages, a switch from normoxia to hypoxia enhanced proliferation of SC. Hypoxia did not affect the expression of SC markers desmin and NCAM. However, the average surface expression per cell of NCAM was downregulated by hypoxia, and it also downregulated the gene expression of NCAM. The gene expression of the myogenic transcription factors PAX7, MYF5, and MYOD was upregulated by hypoxia. Moreover, gene expression of structural proteins α-sarcomeric actin, and myosins MYL1 and MYL3 was upregulated by hypoxia during differentiation. This indicates that hypoxia promotes a promyogenic shift in SC. Finally, Pax7 expression was not influenced by hypoxia and maintained in a subset of mononucleated cells, whereas these cells were devoid of structural muscle proteins. This suggests that during myogenesis in vitro, at least part of the SC adopt a quiescent, that is, reserve cells, phenotype. In conclusion, tissue engineering under hypoxic conditions would seem favorable in terms of myogenic proliferation, while maintaining the quiescent SC pool.