Healing Area Research Articles

NANOPARTICLES FOR SKIN WOUND HEALING

Over the past two decades, there has been a surge in the development of nanoparticle technologies for therapeutic applications. In the area of skin wound healing, silver nanoparticles have been long used as topical antibacterials, but new types of multifunctional nanosystems that can provide more comprehensive therapeutic effects on wounds are being rolled out. The ability to provide a reservoir of bioactive molecules that can be released over time is a feature of many of these systems, which is critically important for nonhealing wounds, where there often is a persistent bacterial load and a chronic lack of growth factors necessary for healing. A great advantage of nanosystems is that by virtue of their extremely small size, they can be easily incorporated into a wide variety of topical treatments that are currently available for use in the clinic. For example, nanoparticles can be easily introduced into decellularized skin products as well as other bioengineered skin substitutes. The design options available for the nanocarriers are very diverse, including encapsulating the drug in the particle's core or presenting it on the outside of the particle, which can also be decorated with a targeting agent, and the ability to change conformation in response to environmental cues (e.g., pH). These various design elements have been optimized differently to treat different types of wounds.

Platelet-Rich Fibrin as a Biofuel for Tissue Regeneration

Wound healing is a staged process which involves the activity of leukocytes and platelets. For this process to work efficiently, the platelets play a vital role. The growth factors present in platelets are important to guide the regenerating cells to the area of healing. Platelet-rich-fibrin (PRF) is one such material that holds on to these growth factors enmeshed in the fibrin network resulting in their sustained release over a period of time that can accelerate the wound healing process. With this knowledge, research has been carried out for a past few years for the clinical application of PRF. Various platelet concentrates have been studied including the platelet-rich-plasma (PRP). However, the short duration of cytokine release and its poor mechanical properties have resulted in the search of a new material with adequate properties for clinical application and ease of preparation. PRF has found a place in the regenerative field owing to its advantages over PRP. This review focuses on the properties and various applications of PRF in the clinical practice.

Stromal Cell-Derived Factor-1 Receptor CXCR4-Overexpressing Bone Marrow Mesenchymal Stem Cells Accelerate Wound Healing by Migrating into Skin Injury Areas

Stromal cell-derived factor-1 (SDF-1) and its membrane receptor C-X-C chemokine receptor type 4 (CXCR4) are involved in the homing and migration of multiple stem cell types, neovascularization, and cell proliferation. This study investigated the hypothesis that bone marrow-derived mesenchymal stem cells (BMSCs) accelerate skin wound healing in the mouse model by overexpression of CXCR4 in BMSCs. We compared SDF-1 expression and skin wound healing times of BALB/c mice, severe combined immunodeficiency (SCID) mice, and immune system-deficient nude mice after (60)Co radiation-induced injury of their bone marrow. The occurrence of transplanted adenovirus-transfected CXCR4-overexpressing male BMSCs in the wound area was compared with the occurrence of untransfected male BALB/c BMSCs in (60)Co-irradiated female mice skin wound healing areas by Y chromosome marker analyses. The wound healing time of BALB/c mice was 14.00±1.41 days, whereas for the nude and SCID mice it was 17.16±1.17 days and 19.83±0.76 days, respectively. Male BMSCs could be detected in the surrounding areas of (60)Co-irradiated female BALB/c mice wounds, and CXCR4-overexpressing BMSCs accelerated the wound healing time. CXCR4-overexpressing BMSCs migrate in an enhanced manner to skin wounds in a SDF-1-expression-dependent manner, thereby reducing the skin wound healing time.

Perceived Health Benefits from Yoga among Breast Cancer Survivors

The purpose of this paper is to describe the health benefits reported by breast cancer survivors following an 8-week yoga intervention. This phenomenological study employed three focus groups with six breast cancer survivors each (n = 18) following the yoga intervention. The focus groups and yoga classes were conducted in a large hospital in a midsized town in the Midwest. Eighteen female breast cancer survivors who were at least 9 months posttreatment participated in the focus groups following the 8-week yoga intervention. An 8-week yoga intervention designed specifically for this population was led by a yoga therapist. A semistructured interview guide was utilized to guide each focus group. Interpretative phenomenological analysis methods were employed to explore breast cancer survivors' experiences after participating in an 8-week yoga intervention. The findings revealed that the women in the study found health promoting benefits in the areas of physical health and healing, mental health and healing, and social health and healing. Yoga may be an important tool in the healing process for breast cancer survivors.

Arthroscopic Transosseous-Equivalent Rotator Cuff Repair

Rotator cuff repair techniques continue to evolve in an effort to improve repair biomechanics, maximize the biologic environment for tendon healing, and ultimately improve patient outcomes. The arthroscopic transosseous-equivalent technique was developed to replicate the favorable tendon-bone contact area for healing seen in open transosseous tunnel repair. In this technical note and accompanying video, we present our all-arthroscopic transosseous-equivalent rotator cuff repair technique with a focus on technical pearls.

Human skin fibroblast response is differentially regulated by galactofucan and low molecular weight galactofucan

Abstract Wound healing is a sum of mechanisms that have to be finely modulated to reconstitute a tissue similar to the original. Several pathologies induce a decrease of healing rate and patients have to be treated to help the closure of wound. Glycosaminoglycan (GAG) mimetics have proven to be valuable in stimulating wound healing. In this study, galactofucan (fucoidan) was extracted from the brown seaweed Saccharina longicruris during two harvest periods (M05 and N05 fractions). Crude galactofucan M05 and N05 were subjected to radical depolymerization (RDP) for 4 h to obtain 2 RDP fractions (M05 RDP and N05 RDP fractions). Each fraction was added on cultured dermal fibroblasts and growth rate, collagen and MMP secretion were analyzed after treatment. Crude and RDP galactofucan influenced fibroblast growth, apoptosis and the synthesis of matrix metalloproteinase (MMP) and collagen according to the molecular weight of the polymer. Both crude galactofucan extracts reduced cell growth and increased MMP secretion, whereas only M05 stimulated apoptosis. By contrast, RDP fractions significantly increased collagen-I secretion and have no negative effect on fibroblast proliferation. Thus, crude and RDP galactofucan exhibit different metabolic activities on fibroblasts, which may be of interest in the area of wound healing.

Modified Femtosecond Laser–Assisted Sutureless Anterior Lamellar Keratoplasty

A variation of the femtosecond laser-assisted sutureless anterior lamellar keratoplasty technique using a femtosecond laser incision for surgical management of anterior corneal disease is described. Six patients with corneal scars were treated with the laser to create a horizontal lamellar bed interface in the cornea of the donor and recipient eyes, with a manual partial-thickness vertical trephination to complete the excisions. This technique allows matching of donor and host tissue dimensions with precise tissue apposition and greater surface area for healing. No intraoperative adverse events were observed. One patient developed epithelial ingrowth, requiring a successful surgical intervention.

Increased ratio of serum matrix metalloproteinase-9 against TIMP-1 predicts poor wound healing in diabetic foot ulcers

ObjectiveLittle is known about serum concentrations of Matrix Metalloproteinase-9 (MMP-9), MMP-2, TIMP-1 and TIMP-2 in diabetic patients with foot ulcers. This study demonstrates their relationship with wound healing. MethodsNinety-four patients with diabetic foot ulcers were recruited in the study. Serum MMP-9, MMP-2, TIMP-1 and TIMP-2 were measured at the first clinic visit and the end of 4-week treatment and followed up till 12weeks. According to the decreasing rate of ulcer healing area at the fourth week, we divided those cases into good and poor healers. Through analyses, we explore the possible relationship among those factors and degree of wound healing. ResultsThe median level of serum MMP-9 in good healers was lower than poor healers at first visit (124.2μg/L vs 374.6μg/L, p<0.05), and after 4-week therapy it decreased 5-fold approximately. In contrast, the change in MMP-9 concentration did not reach statistical significance in poor healers. MMP-2, TIMP-1 and TIMP-2 varied slightly in both good healers and poor healers. The MMP-9/TIMP-1 ratio better reflected the healing than MMP-9 alone before therapy and after 4week treatment (r=−0.6475 vs −0.3251, r=−0.7096 vs −0.1231, respectively). Receiver Operator Curve (ROC) showed that the cutoff for MMP-9/TIMP-1 ratio at <0.395 best predicted a reduction in wound area of 82% at the end of 4-week treatment with a sensitivity of 63.6% and a specificity of 58.6% (area under the curve 0.658, p<0.001). ConclusionsDetecting serum MMP-9/TIMP-1 ratio on admission might be a predictor of healing and might provide a novel target for the future therapy in diabetic foot ulcers.

Holistic Medicine between Religion and Science: A Secularist Construction of Spiritual Healing in Medical Literature

A particular formation can be observed in the discourse of spiritual healing and complementary and alternative medicine (CAM). Explanations of the effectiveness of spiritual healing by medical doctors and psychologists sometimes include ideological and non-scientific conclusions and concepts, which are similar to but also different from New Age science on healing. With discourse analysis discursive nodes and strategies are identified in international medical and psychological research journals at the boundary of CAM, traditional medicine, and psychosomatics from the last decade. The article develops the category of secularism to describe these propositional formations and contributes to the larger debate of postsecular societies. Postsecularism not only puts public religion but also secularisms back on the agenda. This particular secularism in the field of spiritual healing is based on transfers of knowledge and practices between subareas of a functionally differentiated society: esoteric and scientific cultural models shift into medicine, and continue into the area of health care and healing. The article demonstrates how this secularism gathers around key concepts such as emergence, quantum physics, and physicalism, and is engaged in a permanent boundary work between conventional and alternative medicine, which is governed by the notion of holistic healing.

EMF Exposure Facilitates Wound Healing Events Modulating Cytokines Expression

Event Abstract Back to Event EMF Exposure Facilitates Wound Healing Events Modulating Cytokines Expression Erica Costantini1*, Giovina Vianale1*, Chiara D'Angelo1*, Raffaella Muraro1* and Marcella Reale1* 1 Università G.D'Annunzio Chieti-Pescara, Italy Background: During wound repair inflammatory cytokines are upregulated sequentially leading to the activation of keratinocyte growth and migration. IL-1, secreted by the injured keratinocytes, drives both keratinocyte activation and production of TNFα that maintain keratinocytes in their activated state. Activated keratinocytes are hyperproliferative and migratory. Previous studies showed that extremely low frequency electromagnetic fields (ELF-EMF) are able to regulate cytokine expression. Objectives: On this basis the present study aimed to investigate the potential therapeutic use of ELF-EMF, evaluating, in HaCaT cells, the expression of cytokines that orchestrates successful wound. Methods: HaCaT cells were starved for 24 h in serum-free, then wounded with pipette tip to create a cell-free zone. HaCaT cells were exposed at 1 mT, 50Hz and compared to unexposed control cells. Wound healing was evaluated by measuring surface area, percentage and duration of healing. Cytokines expression was evaluated by RT-PCR in EMF-exposed and non-exposed HaCaT cells. Results: After 24 hours the scratch area covered by keratinocyte was increased in EMF-exposed compared to non-exposed samples, in accord with the observed cell proliferation induced by EMF. Moreover, in EMF-exposed HaCaT expression of IL-1, TNFa, IL-18 and MMP-2 was increased and IL-10, IL-18BP and MMP-9 was decreased. Conclusion: The ELF-EMF-enhanced expression of cytokines responsible for HaCaT proliferation and activation suggest an increased capacity of keratinocytes to reepithelialize the margin of wound avoiding the non-healing wounds. The ability of ELF-EMF to modulate cytokines expression highlights the potential therapeutic role of ELF-EMF in wound healing processes. Keywords: Wound Healing, keratinocyte, fibroblast, electromagnetic field, proliferation, Migration, RT-PCR Conference: 15th International Congress of Immunology (ICI), Milan, Italy, 22 Aug - 27 Aug, 2013. Presentation Type: Abstract Topic: Immune-mediated disease pathogenesis Citation: Costantini E, Vianale G, D'Angelo C, Muraro R and Reale M (2013). EMF Exposure Facilitates Wound Healing Events Modulating Cytokines Expression. Front. Immunol. Conference Abstract: 15th International Congress of Immunology (ICI). doi: 10.3389/conf.fimmu.2013.02.00390 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 15 Mar 2013; Published Online: 22 Aug 2013. * Correspondence: Dr. Erica Costantini, Università G.D'Annunzio Chieti-Pescara, Chieti, Italy, erica.costantini@unich.it Dr. Giovina Vianale, Università G.D'Annunzio Chieti-Pescara, Chieti, Italy, gvianale@unich.it Dr. Chiara D'Angelo, Università G.D'Annunzio Chieti-Pescara, Chieti, Italy, chiara_dangelo@hotmail.it Prof. Raffaella Muraro, Università G.D'Annunzio Chieti-Pescara, Chieti, Italy, muraro@unich.it Prof. Marcella Reale, Università G.D'Annunzio Chieti-Pescara, Chieti, Italy, mreale@unich.it Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Erica Costantini Giovina Vianale Chiara D'Angelo Raffaella Muraro Marcella Reale Google Erica Costantini Giovina Vianale Chiara D'Angelo Raffaella Muraro Marcella Reale Google Scholar Erica Costantini Giovina Vianale Chiara D'Angelo Raffaella Muraro Marcella Reale PubMed Erica Costantini Giovina Vianale Chiara D'Angelo Raffaella Muraro Marcella Reale Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Investigation of The Wound Healing Effects of Chitosan on FGFR3 and VEGF Immunlocalization in Experimentally Diabetic Rats

Chitosan is a naturally occurring substance that stimulates correct deposition, assembly and orientation of collagen fibres in extracellular matrix components in wounds and promotes migration of inflammatory cells. Fibroblast growth factor (FGF) is one of the most important growth factors playing crucial roles in angiogenesis and wound healing. Biologically, it acts via binding to the cellular surface receptors. FGFR3 is one of the most important receptors. Therefore the aim of the present study was to investigate, histologically and histochemically, the effect of chitosan on wound healing in experimentally diabetic rats divided into four groups. When compared to the diabetic and the control groups, chitosan group had more inflammatory cells, endothelial cells, newly formed blood vessels and reticular – collagen fibres in the wound healing area from the third day of operation.Moreover, in Chitosan Group, stronger VEGF and FGFR3 immunolo-calizations were evident and all steps of wound healing process were more regular. FGFR3 antibody used in this study had been tested only on diabetic wound healing. In conclusion, we have concluded that application of chitosan was essential to accelarate wound healing process in diabetic patients

Comparative Study of the Effects of Recombinant Human Epidermal Growth Factor and Basic Fibroblast Growth Factor on Corneal Epithelial Wound Healing and Neovascularization in vivo and in vitro

Purpose: This study was undertaken to investigate the effects of recombinant human epidermal growth factor (rhEGF) and basic fibroblast growth factor (bFGF) on corneal wound healing and neovascularization (CNV). Methods: The positive effects of 10 ng/ml rhEGF and bFGF on the proliferation of corneal epithelial cells (SD-HCEC1s), rabbit keratocyte cells (RKCs) and human umbilical vein endothelial cells (HUVECs) as well as the effects on the migration capacity on HUVECs were observed. An animal central corneal wound and CNV model was established in rabbits. One eye of each group was chosen randomly for topical administration of rhEGF, bFGF or normal saline, and variability in the area of corneal epithelial wound healing and CNV was observed. Results: The optimal concentration of rhEGF and bFGF for the proliferation of corneal epithelial cells was 10 ng/ml. The promotive effect of 10 ng/ml rhEGF on the proliferation of RKCs and HUVECs was less than that of 10 ng/ml bFGF. In the animal experiment, the healing rate of the corneal epithelium in the rhEGF group was better than in the other groups on day 1. On day 3, the healing rates of the 3 groups were nearly equal. The CNV area in the rhEGF group was less than that of the bFGF group. Conclusions: rhEGF and bFGF both had promotive effects on corneal epithelial wound healing, but rhEGF had a weaker promotive effect on CNV than bFGF. With long-term application of growth factor drugs, rhEGF is suggested for lessening the growth of CNV.

Wedge volume and osteotomy surface depend on surgical technique for distal femoral osteotomy

Biplanar distal femoral osteotomy (DFO) is thought to promote rapid bone healing due to the increased cancellous bone surface compared to other DFO techniques. However, precise data on the bone surface area and wedge volume resulting from both open- and closed-wedge DFO techniques remain unknown. We hypothesized that biplanar rather than uniplanar DFO better reflects the ideal geometrical requirements for bone healing, representing a large cancellous bone surface combined with a small wedge volume. Femoral saw bones were assigned to 4 different groups of varization distal femur osteotomies: group 1, lateral open-wedge uniplanar DFO; group 2, medial closed-wedge uniplanar DFO; group 3, lateral open-wedge biplanar DFO; and group 4, medial closed-wedge biplanar DFO. Bone surface areas of all osteotomy planes were quantified. Wedge volumes were determined using a prism-based algorithm, applying standardized wedge heights of 5, 10 and 15mm. The biplanar osteotomy techniques (groups 3 and 4) created significantly larger femoral surface compared to the uniplanar groups (groups 1 and 2) (p=0.036). Bone surfaces after the lateral biplanar open-wedge technique (group 3) were slightly larger than the medial biplanar closed-wedge technique (group 4) and biplane techniques significantly larger than the uniplanar techniques (groups 1 and 2). Wedge volumes were significantly higher in the lateral uniplanar open-wedge (group 1) and biplanar open-wedge (group 3) techniques compared to the closed-wedge techniques (groups 2 and 4) that have nearly absent wedge volumes. Bone geometry following DFO suggests that the medial biplanar closed-wedge technique simultaneously creates smaller wedge volume and larger bone surface areas compared to the lateral biplanar open-wedge and the uniplanar DFO techniques. The horizontal cuts of the biplane DFO techniques are positioned behind the trochlear area in better healing metaphysial bone, which further enhances bone healing potential. Although this idealized geometric view on bony geometry excludes all biological factors that influence bone healing, the current data confirm the general rule for osteotomy techniques: reducing the amount of slow gap healing and wedge volumes and simultaneously increasing the area of faster contact healing by larger bone surface areas may be beneficial for osteotomy healing.

Acute mucosal radiation reactions in patients with head and neck cancer

The goal of this research was to evaluate the healing processes of acute mucosal radiation reactions (AMRR) in patients with head and neck cancer. In 46patients with oral and oropharyngeal cancer patients irradiated with conventional (n = 25) and accelerated (n = 21) dose fractionation AMRR was evaluated daily during and after radiotherapy. Complex of morphological and functional symptoms according to the Dische score were collected daily until complete healing. Duration of healing after the end of radiotherapy ranged widely (12-70days). It was on the average 8days longer for accelerated than for conventional radiotherapy (p = 0.016). Duration of dysphagia was also longer for accelerated irradiation (11days, p = 0.027). Three types of morphological symptoms were observed as the last symptom at the end of AMRR healing: spotted and confluent mucositis, erythema, and edema. Only a slight correlation between healing duration and area of irradiation fields (r = 0.23) was noted. In patients with confluent mucositis, two morphological forms of mucosal healing were observed, i.e., marginal and spotted. The spotted form was noted in 71% of patients undergoing conventional radiotherapy and in 38% of patients undergoing accelerated radiotherapy. The symptoms of mucosal healing were observed in 40% patients during radiotherapy. The wide range of AMRR healing reflects individual potential of mucosa recovery with longer duration for accelerated radiotherapy. Two morphological forms of confluent mucositis healing were present: marginal and spotted. Healing of AMRR during radiotherapy can be observed in a significant proportion of patients.

Accelerated Bone Healing in the Absence of TLR4

OBJECTIVEToll‐like receptor 4 (TLR4) is a member of highly conserved receptor family and is a critical activator of the innate immune response after tissue injury. TLR4 signaling has been shown to regulate both the immune response and bone metabolism during long‐bone fracture healing. Unlike defects in long bones, defects in the calvaria often do not heal. Here we tested the hypothesis that the inflammation driven by TLR4 activation limits the healing of calvarial defects.METHODSCircular bone defects were made in the parietal bones using a 1.8mm outer diameter trephine in WT (n=32) and TLR4−/− mice (n=24). Calvarial bone and surrounding soft tissues (e.g. skin and brain) were harvested and bone healing was assessed using histomorphology at postoperative days 0, 1, 2, 4, 7, 14, 21 and 28.RESULTSHistomorphometric analysis demonstrated significantly larger bone healing areas in TLR4−/− mice compared to WT mice on day7 (p&lt;0.001). Similar levels of bone healing were observed by day 28 (p=0.070).CONCLUSIONSThese data are consistent with the hypothesis that TLR4 activation delays calvarial healing in mice. Further work is required to determine if this is due to inflammation driven by TLR4 activation.

Advances in Wound Healing: A Review of Current Wound Healing Products

Successful wound care involves optimizing patient local and systemic conditions in conjunction with an ideal wound healing environment. Many different products have been developed to influence this wound environment to provide a pathogen-free, protected, and moist area for healing to occur. Newer products are currently being used to replace or augment various substrates in the wound healing cascade. This review of the current state of the art in wound-healing products looks at the latest applications of silver in microbial prophylaxis and treatment, including issues involving resistance and side effects, the latest uses of negative pressure wound devices, advanced dressings and skin substitutes, biologic wound products including growth factor applications, and hyperbaric oxygen as an adjunct in wound healing. With the abundance of available products, the goal is to find the most appropriate modality or combination of modalities to optimize healing.

Potential Applications of Digital Pathology and Image Analysis for Forensic Pathology

The analysis of digital images using computer algorithms to mine digital data directly is an important and increasingly utilized tool in many different fields of medicine. However, despite the clear value of image analysis to forensics, there is little research and no current practical applications of this technology to forensic pathology. This paper demonstrates the technique of Spatially Invariant Vector Quantization (SIVQ) in the analysis of gross forensic images. SIVQ is a pattern recognition algorithm that can run on a laptop and be utilized by a forensic pathologist with no programming experience. The user merely points and clicks to the feature of interest and SIVQ searches the entire image for the desired feature. The results can be displayed in a variety of formats, both qualitative and quantitative. Gross forensic images from gunshot wounds, burns and patterned contusions were analyzed by a forensic pathologist using SIVQ. Based on features selected by the user, the algorithm was able to detect both the gunshot wound and its marginal abrasion, calculate the surface area of a gunshot wound defect, distinguish between a thermal burn and the surrounding areas of healing, analyze a patterned contusion, and both identify and calculate the density of gunpowder stippling. Even though the work is preliminary, it is obvious from these few examples that SIVQ is easily able to identify features of interest in gross forensic images. Additional work needs to be done to fully explore the potential for this application of technology to the practice of forensic pathology.

Subscapularis Release in Shoulder Replacement Determines Structural Muscular Changes

Osteotomy of the lesser tuberosity in shoulder arthroplasty allows bony healing of the subscapularis tendon but does not prevent fatty degeneration in its muscle. Occurrence or increase in fatty degeneration may depend on the surgical technique. We (1) assessed fatty degeneration in the subscapularis muscle and its cross-sectional area after a C-block osteotomy of the lesser tuberosity with minimal mobilization of the subscapularis muscle, and (2) determined whether this technique had any adverse effect on function, fatty degeneration, and cross-sectional area of the subscapularis muscle. We retrospectively examined 36 patients with shoulder replacements who had C-block osteotomies. Constant-Murley scores and clinical signs of subscapularis insufficiency were recorded. We radiographically assessed prosthetic placement. On CT scans, lesser tuberosity healing, fatty degeneration, and cross-sectional area of the subscapularis muscle were determined. The minimum followup was 13 months (mean, 18 months; range, 13-33 months). The mean absolute Constant-Murley score was 71.2. Two patients had weakness of the subscapularis muscle without loss of active motion. All tuberosities healed anatomically. A normal glenohumeral relationship was found in all cases. Fatty degeneration was Grade 0 in 44%, Grade 1 in 39%, Grade 2 in 14%, and Grade 3 in 3%. The subscapularis muscular cross-sectional area decreased from 16.7 cm(2) preoperatively to 14.5 cm(2) postoperatively (13%). The C-block osteotomy with minimal dissection of the subscapularis is associated with a low incidence of fatty degeneration in the subscapularis muscle after shoulder arthroplasty although the muscular cross-sectional area of the subscapularis decreased. Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Wedge volume and osteotomy surface depend on surgical technique for high tibial osteotomy

Biplanar open-wedge high tibial osteotomy (HTO) is thought to promote rapid bone healing due to the increased cancellous bone surface compared to other HTO techniques. However, precise data on the bone surface area and wedge volume resulting from both open- and closed-wedge HTO techniques remain unknown. We hypothesized that biplanar rather than uniplanar HTO better reflects the ideal geometrical requirements for bone healing, representing a large cancellous bone surface combined with a small wedge volume. Tibial saw bones were assigned to 4 different groups of valgisation high tibial osteotomies: group 1: open-wedge uniplanar HTO; group 2: open-wedge biplanar HTO with ascending frontal cut; group 3: open-wedge biplanar HTO with descending frontal cut (retrotubercule osteotomy technique), and group 4: closed-wedge uniplanar HTO. Bone surface areas of all osteotomy planes were quantified. Wedge volumes were determined using a prism-based algorithm, applying standardized wedge heights of 5, 10, and 15 mm. The open-wedge biplanar osteotomy with a descending frontal cut (group 3) created significantly larger bone surfaces compared to the “classic” biplanar technique with an ascending frontal cut (group 2) and compared to all uniplanar techniques. Bone surfaces after the classic open-wedge technique (group 2) were slightly larger compared to all uniplanar techniques (group 1 and 4). No significant differences of wedge volumes were found between the retrotubercle (group 3) and classic open-wedge techniques (group 2). Wedge volumes were significantly higher in the uniplanar open-wedge technique (group 1) compared to the biplanar open-wedge techniques (group 2 and 3). Bone geometry following HTO suggests that the biplanar open-wedge techniques simultaneously create smaller wedge volumes and larger bone surface areas compared to the uniplanar open-wedge techniques. The relatively neglected closed-wedge technique still offers in theory the best healing potential, characterized by an almost absent wedge volume and a large bone-to-bone contact area. Although this idealized geometric view on bony geometry excludes all biologic factors that influence bone healing, the current data suggest a general rule for the applied standard osteotomy techniques and all of their surgical modifications: reducing the amount of slow gap healing and simultaneously increasing the area of faster contact healing may be beneficial for osteotomy healing. Thus, a biplanar rather than a uniplanar osteotomy may be performed for high tibial osteotomy in clinical practice.

We Are ‘Woman’, after All

Thandi was a 16 year old schoolgirl, when I first met her at a local state Hospital in Johannesburg, South Africa. She was referred for genetic counselling as she had recently been diagnosed with mosaic Turner Syndrome (TS). I remember being nervous beforehand as I knew I would not be able to inform her about the impact of TS because of the variable phenotype, which in her case was further complicated by the presence of mosaicism. Early in the session my concern of not being able to assure her was confirmed and so began our journey into exploring womanhood. I immediately connected with Thandi, with her radiant smile and nervous adolescent giggles. She started telling her story; she was one of three children from a socially disadvantaged background. She was granted a scholarship at a prestigious all-girl private school because of her academic and sporting achievements. This was an honour for her, and she was clearly motivated to succeed. Although liked by the other schoolgirls, she felt self-conscious about her body and embarrassed by her lack of breasts and periods. She took it upon herself to find out what was happening, and this resulted in her diagnosis. She was blase in telling me about the diagnosis and possible lack of uterus and ovaries, and I felt panicked as I realised that she knew the name of her condition but was unaware of the impact. Thandi understood my explanation of TS but her question to me “Why me?” caught me off guard. I needed an answer for her. It seemed “unfair” that this young woman, who had risen above many obstacles, was dealt this hand. We both seemed to fall into a state of helplessness, although she still seemed strong. The final blow to her resolve was the high risk for infertility. She was visibly devastated and she exposed her shame when asking whether she was like Caster Semenya. Caster is a South African gold-medalist athlete whose gender was being questioned and the means to “define gender” was a major news item at the time. As the worldwide sports governing bodies tried to determine how to define gender, insensitive and harsh comments were often made with little regard for Caster and her family. Here was Thandi, also an athlete, who now turned the same scrutiny on herself and had the insight to know that in order to attain some acceptance she would need to meet the world’s criteria. But more importantly, she had her own definition of being a woman, and she would need to be able to align herself with it; otherwise, she could lose her sense of self-acceptance and self-worth. By acknowledging her feelings of shame I tried to normalise her loss of identity and reduce the shock. Thandi left saying she was pleased to know more about TS but found the infertility issue difficult to accept. Thus, she provided a big clue to how she defines womanhood. I felt overwhelmed, not just for Thandi but also for myself. Here I was, in my 30s, thinking I understood my world but confounded by the simple question, “What defines women?” I was shocked that even knowing the physiological complexities involved in gender, I still thought of it in simple measurable terms: chromosomes & physiological features, both easily definable and socially acceptable. But on witnessing how the loss of a chromo1 Name changed for anonymity