Correction of severe facial deformity.

A craniofacial team has been developed to corrdinate the treatment of patients with severe facial deformity and to minimize the surgical risks. Two hundred patients have been evaluated in the last 4 years and more than 100 treated by this team to correct orbital hypertelorism, oxycephaly and plagiocephaly with exophthalmos, features of Crouzon''s disease and Apert''s and Treacher Collins syndromes, hemifacial microsomia, and severe lower facial deformity and malocclusion. Surgical principles include extensive subperiosteal stripping of bone, osteotomy as necessary, and repositioning maintained by bone grafts. Postoperative evaluation is being maintained for 5 years or to maturity in younger children. Although many of the results are less than perfect, there has been sufficient improvement, especially psychologic and functional, to warrant continuation of the surgical program under closely controlled conditions.     

Expandable breast implant reconstruction of Tikhoff-Linberg shoulder deformity

Expanding breast implants were used in two patients to reconstruct shoulder contour following a Tikhoff-Linberg resection for cancer. In the first patient, one implant alone was used, and in the second patient, two implants in separate but adjacent pockets. The resulting double contour is more pleasing than that after a single implant, and there also appears to be more flexibility with shoulder motion. This method is suggested as an excellent means of reconstructing the contour of the shoulder area following resection for cancer.     

Correction of pincer-nail deformity using dermal grafting

Pincer-nail syndrome has been described as distortion in the shape of the nails with excessive transverse curvature of the plate that increases from proximal to distal, leading to pinching and loss of soft tissue in the affected digit, resulting in severe pain. Many treatments have been recommended, but an effective long-term method that preserves the nail matrix has not been described. A method of dermal grafting under the nail matrix is described, and the results of treatment of six digits are reported. Five women and one man with an average age of 52 were treated. The affected digit was the thumb in four patients and the great toe in two patients. Follow-up averaged 25 1/2 months. The results were good in all cases with only one side of one nail remaining slightly curved. Pain was relieved in all cases, and complete adherence of the new nail plate occurred. Dermal grafting seems to provide excellent long-term treatment of the pincer-nail deformity with preservation of the nail matrix.     

Effects of an improved biomechanical backpack strap design on load transfer to the shoulder soft tissues

The aim of the present study was to characterize shoulder strap structure and mechanical properties that may alleviate strains and stresses in the soft tissues of the shoulder. Utilizing a finite element model of the shoulder constructed from a single subject, we have quantified skin stresses exerted by backpack straps and the strains at the subclavian artery (SCA). For this end, standard shape straps with stiffness of 0.5, 1.2, and 5 MPa, were compared to the effects of optimized straps; a double-layered (soft outer layer and reinforced internal supporting layer) and newly-designed anatomically-shaped strap. Compared to the standard 0.5 MPa strap, the 5 MPa strap resulted in 4-times lower SCA strains and 2-times lower Trapezius stresses. The double-layered strap resulted in 40% and 50% reduction in SCA strains and skin stresses, respectively, with respect to the softer strap. The newly-designed anatomical strap exerted 4-times lower SCA strains and 50% lower skin stresses compared to the standard strap. This demonstrates a substantial improvement to the load carriage ergonomics when using a composite anatomical strap.     

Activation of shoulder muscles in healthy men and women under isometric conditions

Purpose: Due to the low osseous lead of the shoulder joint a large portion of the shoulder muscles, in addition to executing movements, deals with stabilising tasks. This requires a permanent readjustment of the intermuscular co-ordination of all involved muscles. The aim of the study was to verify the existence of gender dependent differences in intramuscular co-ordination patterns of shoulder muscles.

Method: Fifteen healthy men and nine healthy women, who executed 24 isometric exercises in sagittal, frontal and horizontal planes with a loading of 50% of their individual isometric maximum force, were investigated. In every plane, four angular positions were chosen and both opposite force directions were measured, respectively. SEMG was taken from 13 muscles of the shoulder and the upper arm. Due to inter-individual differences SEMG amplitudes were normalised. Results: Gender specific differences of functional intermuscular co-ordination patterns could be proven systematically. Women showed less activation of muscles acting in the main force direction. In addition, those muscles less necessary for the actual force production were more activated in women than in men.

Conclusions: Functionally comparable shoulder function showed a gender dependency in terms of functional intermuscular co-ordination.     

Bipedicle strap flaps in reconstruction of longitudinal dorsal skin defects of the digits

Dorsal skin defects in which the loss of integument is longitudinal in shape are not uncommon after injury by rotating machinery and by glass shearing along the length of the digit. This shape of defect is difficult to reconstruct with commonly used flaps but lends itself to reconstruction by the use of longitudinal bipedicle strap flaps moved across the dorsum of the finger from lateral to medial. A variant of this traditional technique was used in the reconstruction of 28 dorsal digital defects. The incidence of these defects and the need for this reconstructive technique were analyzed by a review of 1077 patients with dorsal digital injuries treated in a 6-year period between 1989 and 1995. Approximately 20 percent of all dorsal digital injuries requiring flap reconstruction were suitable for reconstruction with bipedicle strap flaps.     

Leash in the groove mechanism of membrane fusion

Formation of helix bundles has been proposed as a general mechanism for viral and cellular membrane fusion reactions. Class I viral fusion proteins, including HIV Env and influenza hemagglutinin (HA), form six-helix bundles in their fusogenic forms. The HIV Env six-helix bundle extends to the membrane proximal end of the protein, where it is poised to pull the fusing membranes together. In contrast, the HA six-helix bundle is located at the membrane distal end of the protein. It is followed by a C-terminal 'leash' that packs into the grooves and extends to the membrane proximal end of the coiled-coil. Here, we describe the ability of C-terminal leash mutants to change conformation and induce fusion. Our data indicate that packing of the C-terminal leash into the grooves of the coiled-coil is necessary for HA to mediate the lipid mixing stage of fusion, and that hydrophobic membrane proximal leash residues secure this interaction. Therefore, HA employs a 'leash in the groove,' rather than a helix-bundle, mechanism of membrane fusion.     

Anatomy of the Caucasian alar groove

Anatomic studies performed on the noses of 15 cadavers examined the alar groove, alar lobule, and lower lateral crus areas both microscopically and on gross appearance to determine what effect these structures have on overall nasal appearance. In contrast to the findings of previous studies, the authors found the alar lobule to be an area in which dermis is interdigitated with muscle throughout and up to the alar rim. The anteroposterior lengths of the lower lateral crura were again seen to vary in length, presence or absence of accessory cartilages, and shape. Neither corrugation of the posterior elongation nor overlap of the accessory cartilages of the lower lateral cartilage had an effect on phenotype; sharp angles formed by the cartilage were blunted by the layer of fibrofatty muscular tissue between the cartilage and the skin. The alar groove, which lies at the junction of the lower lateral crus (medially) and the alar lobule (laterally), is defined not as much by a muscular attachment between the perichondrium of the lower lateral cartilage and the vestibular mucosa as by a bulging in the fatty layer on one side of the groove (within the cheek, lateral nasal wall, and nasal tip) and a relative paucity of fatty tissue on its other side (within the alar lobule).     

An MRI study on the relations between muscle atrophy, shoulder function and glenohumeral deformity in shoulders of children with obstetric brachial plexus injury

Objective

it has been established that chronic neck pain following whiplash is associated with the phenomenon of central sensitization, in which injured and uninjured parts of the body exhibit lowered pain thresholds due to an alteration in central pain processing. it has furthermore been hypothesized that peripheral sources of nociception in the muscles may perpetuate central sensitization in chronic whiplash. the hypothesis explored in the present study was whether myofascial trigger points serve as a modulator of central sensitization in subjects with chronic neck pain.

Design

controlled case series.

Setting

outpatient chronic pain clinic.

Subjects

seventeen patients with chronic and intractable neck pain and 10 healthy controls without complaints of neck pain.

Intervention

symptomatic subjects received anesthetic infiltration of myofascial trigger points in the upper trapezius muscles and controls received the anesthetic in the thigh. Outcome measures: pre and post injection cervical range of motion, pressure pain thresholds (ppt) over the infraspinatus, wrist extensor, and tibialis anterior muscles. sensitivity to light (photophobia) and subjects' perception of pain using a visual analog scale (vas) were also evaluated before and after injections. only the ppt was evaluated in the asymptomatic controls.

Results

immediate (within 1 minute) alterations in cervical range of motion and pressure pain thresholds were observed following an average of 3.8 injections with 1–2 cc of 1% lidocaine into carefully identified trigger points. cervical range of motion increased by an average of 49% (p = 0.000) in flexion and 44% (p = 0.001) in extension, 47% (p = 0.000) and 28% (p < 0.016) in right and left lateral flexion, and a 27% (p = 0.002) and 45% (p = 0.000) in right and left rotation. ppt were found increased by 68% over the infraspinatus (p = 0.000), by 78% over the wrist extensors (p = 0.000), and by 64% over the tibialis anterior (p = 0.002). among 11 subjects with photophobia, only 2 remained sensitive to light after the trigger point injections (p = 0.033). average vas dropped by 57%, from 6.1 to 2.6 (p = 0.000). no significant changes in ppt were observed in the control group following lidocaine infiltration of the thigh.

Conclusion

the present data suggest that myofascial trigger points serve to perpetuate lowered pain thresholds in uninjured tissues. additionally, it appears that lowered pain thresholds associated with central sensitization can be immediately reversed, even when associated with long standing chronic neck pain. although the effects resulting from anesthesia of trigger points in the present study were temporary, it is possible that surgical excision or ablation of the same trigger points may offer more permanent solutions for chronic neck pain patients. further study is needed to evaluate these and other options for such patients.