Use of vastus lateralis muscle flap for repair of trochanteric pressure sores.

The use of a vastus lateralis muscle flap is suggested as an approach to the surgical repair of trochanteric pressure sores in paraplegic patients. The details of the anatomy of the muscle are outlined, and our surgical technique for its use is described.     

Distally based vastus lateralis muscle flap for coverage of wounds about the knee

The blood supply to the vastus lateralis muscle has been evaluated by dye injection techniques in fresh cadaver dissections. The main dominant blood supply is the descending branch of the lateral femoral circumflex artery. Vascular contributions from distal perforators of the superficial femoral artery, the superior geniculate artery, fill the main vascular pedicle in a retrograde fashion. Latex staining is observed consistently in the proximal third of the muscle. Five patients are presented in whom the distally based vastus lateralis muscle flap was successfully used to cover defects above the knee. Superficial muscle necrosis is a complication of this operation but has not precluded its usefulness. It is anticipated that this flap will be useful in the armamentarium of reconstructive surgeons treating such problematic patients.     

Pelvic instability and trunk and hip muscle recruitment patterns in patients with total hip arthroplasty

Hip and lumbar spine disorders often coexist in patients with total hip arthroplasty (THA). The current study aimed to reveal pelvic motion pathology and altered trunk and hip muscle recruitment patterns relating to pelvic motion in patients with THA. Twenty-one women who underwent THA and 12 age-matched healthy women were recruited. Pelvic kinematics and muscle recruitment patterns (i.e., amplitude, activity balance, and onset timing) of the gluteus maximus, semitendinosus, multifidus, and erector spinae were collected during prone hip extension. Compared with healthy subjects, the patients showed increased pelvic motion, especially ventral rotation, decreased multifidus muscle activity relative to the hip extensors, and delayed onset of multifidus activity, despite reaction times and speeds of leg motion not being significantly different between the groups. Furthermore, while contributing factors associated with ventral pelvic rotation were not found, delayed onset of multifidus activity was detected as a factor related to the increased anterior tilt of the pelvis (r = 0.47, p < 0.05) in patients with THA. These results suggest that patients with THA have dysfunction of the stabilizer muscles of the lumbopelvic region along with increased pelvic motion.     

Quantitative analysis of changes occurring in muscle vastus lateralis in patients with heart failure after low-intensity training

OBJECTIVE: To quantitate the changes occurring in muscle vastus lateralis after exercise training of low intensity adopted for the rehabilitation of patients with chronic heart failure. STUDY DESIGN: Nine consecutive males with a clinical diagnosis of idiopathic dilated and ischemic cardiomyopathy underwent an eight-week period of training. The intensity of the work was calculated as 40% of peak VO2. The program consisted of 30 minutes of cycling three times per week. A cardiopulmonary exercise test, hemodynamic measurements and echocardiographic studies were carried out. Needle biopsies were taken from muscle vastus lateralis before starting and after completing training. Quantitative analysis was carried out on sections stained with ATPase at pH 9.5 for measurement of the lesser diameter of type 1 and 2 fibers (by using an image analyzer) and on UEA 1-stained sections for capillary density and capillary/fiber ratio (by using a frame in the eyepiece of the microscope). The Wilcoxon test was applied to identify significant differences before and after training. Spearman's rank correlation coefficient was also calculated to highlight any correlation between the morphologic data and results of clinical tests. RESULTS: After completing the training program, all the patients experienced an improvement in exercise tolerance and a significant increase (P < .004) in the VO2 and VCO2 peak. Skeletal muscle showed a significant (P < .02) increase in the capillary/fiber ratio. The changes were not significantly correlated with any of the clinical findings. CONCLUSION: Low-intensity training can improve the functional capacity of patients with heart failure while producing only mild morphologic changes in their muscles.     

Capillary density and capillary-to-fibre ratio in vastus lateralis muscle of untrained and trained men

Muscle fibre profile area (Af), volume density (Vv), capillary-to-fibre ratio (CF) and number of capillaries per fibre square millimetre (CD) were determined from needle biopsies of vastus lateralis of twenty-four male volunteers (mean +/- SD: age 25.4+/-5.8 years, height 178.6+/-5.5 cm, body mass 72.1+/-7.7 kg) of different training background. Seven subjects were untrained students (group A), nine were national and sub-national level endurance athletes (group B) with the background of 7.8+/-2.9 years of specialised training, and eight subjects were sprint-power athletes (group C) with 12.8+/-8.7 years of specialised training. Muscle biopsies of vastus lateralis were analysed histochemically for mATPase. Capillaries were visualized and counted using CD31 antibodies against endothelial cells. There were significant differences in the Vv of type I and type II muscle fibres in both trained groups, B (51.8%; 25.6%) and C (50.5%; 26.4%). However, in untrained group A that was treated as a reference group, the difference between Vv of type I and type II fibres was less prominent, nevertheless statistically significant (42.1%; 35.1%). There was also a significant difference in CF: 1.9 in group A and 2.1 in groups B and C. The number of capillaries per mm2 (CD) was 245 (group A), 308 (group B) and 325 (group C). Significant differences (P<0.05) in CF and CD, were found only between group A (1.9; 245) and both groups of trained men, B and C (2.1; 308 and 325). However, endurance athletes (group B), such as long-distance runners, cyclists and cross country skiers, did not differ from the athletes representing short term, high power output sports (group C) such as ice hockey, karate, ski-jumping, volleyball, soccer and modern dance.     

Fiber type composition of the vastus lateralis muscle of young men and women.

This study presents data collected over the past 10 years on the muscle fiber type composition of the vastus lateralis muscle of young men and women. Biopsies were taken from the vastus lateralis muscle of 55 women (21.2+/-2.2 yr) and 95 men (21.5+/-2.4 yr) who had volunteered to participate in various research projects. Six fiber types (I, IC, IIC, IIA, IIAB, and IIB) were classified using mATPase histochemistry, and cross-sectional area was measured for the major fiber types (I, IIA, and IIB). Myosin heavy chain (MHC) content was determined electrophoretically on all of the samples from the men and on 26 samples from the women. With the exception of fiber Type IC, no significant differences were found between men and women for muscle fiber type distribution. The vastus lateralis muscle of both the men and women contained approximately 41% I, 1% IC, 1% IIC, 31% IIA, 6% IIAB, and 20% IIB. However, the cross-sectional area of all three major fiber types was larger for the men compared to the women. In addition, the Type IIA fibers were the largest for the men, whereas the Type I fibers tended to be the largest for the women. Therefore, gender differences were found with regard to the area occupied by each specific fiber type: IIA>I>IIB for the men and I>IIA>IIB for the women. These data establish normative values for the mATPase-based fiber type distribution and sizes in untrained young men and women.     

Comparison of the muscle activation pattern for the vastus lateralis before and after an 8-week resistance training program

The purpose of this investigation was to use wavelet analyses and pattern classification techniques to examine potential changes in the joint time–frequency distribution of surface electromyographic (EMG) signals due to an 8-week resistance training program. Thirteen untrained men (mean ± S.D. age = 22.2 ± 4.0 yrs) performed eight separate submaximal isometric muscle actions of the dominant leg extensors in 10% increments from 10 to 80% of the maximum voluntary contraction (MVC). During each muscle action, a monopolar surface EMG signal was detected from the vastus lateralis. All signals were then analyzed with a wavelet analysis designed specifically for EMG signals, and the resulting intensity patterns were classified using pattern classification techniques into their respective pre-training versus post-training categories. The results showed accuracy rates (% of correctly classified patterns) that ranged from approximately 62 to 92%, but these rates did not change consistently with increases in force. In addition, for five of the eight submaximal force levels, the classification was considered to be significantly different from random. Thus, although the differences between the pre- and post-training EMG intensity patterns were not always consistent, our findings did suggest that there is the potential for wavelet analyses and pattern classification techniques to be used to examine neuromuscular adaptations during resistance training.     

Retransfusion of unwashed drainage blood after total hip and knee arthroplasty]

The method of retransfusion of drainage blood as known from the literature was investigated in a prospectiv study regarding effectivness and rate of side effects. 200 patients who underwent total hip and knee arthroplasty were investigated concerning hemoglobin, hematocrit, amount and quality of the retransfused drainage blood, the amount of autologous and homologous transfusions as well as complications and costs. 100 of these patients were selected as the control group. The amount of the retransfused drainage blood after hip arthroplasty amounted an average of 387 +/- 194 ml and after knee arthroplasty 595 +/- 250 ml. The retransfused blood had an average hemoglobin of 5,2 +/- 0,9mmol/l with a hematocrit of 0,24 0,05. No complications directly associated to the retransfusion were found. The need of transfusion was reduced for patients with knee arthroplasty about 30% and for hip arthroplasty about 25%. The retransfusion of unwashed drainage blood is a sufficient method to reduce perioperative homologous blood transfusion in patients with arthroplasty of hip and knee. Substantial complications were not observed, so that this method seems to be save enough for clinical usage. The method is easy to handle and usable without special technical devices. The autologous retransfusion of drainage blood can contribute to lower costs in patients treatement.     

Quality of the blood sampled from surgical drainage after total hip arthroplasty

Several methods have been found to be successful in reducing the need for allogeneic transfusion among the patients undergoing total hip replacement. The purpose of this prospective study was to analyse the quality and evaluate the effect of postoperative autotransfusion on the need for allogeneic transfusion following total hip replacement. The prospective study was performed in two groups of patients undergoing total hip replacement. Before the operative procedure all patients in both groups predonated two doses of autologous blood. In GROUP 1. the system for postoperative collection and transfusion of shed blood was used. In GROUP 2. the patients underwent total hip replacement without blood salvage system. Standard suction collection sets were used postoperatively. In this group shed blood was not transfused to the patients. The samples of preoperative donated autologus blood, allogeneic blood and postoperative collected autologous blood were analysed for number of red cells, hemoglobin, hematocrit, platelets, white blood cells, values of potassium, sodium, free hemoglobin and acid base status. The postoperatively blood salvage significantly reduced the use of allogeneic transfusion among patients managed with total hip replacement (allogeneic transfusion received 12% patients in Group 1 and 80% patients in Group 2; p<0.001). The values of red blood cells are significantly lower in postoperative collected autotransfusion blood compared with preoperative collected autologous blood and allogeneic blood (p<0.001). The values of potassium and acid base status were in normal range in postoperatively collected autotransfusion blood. These values in preoperatively collected autologous blood and allogeneic blood were out of normal range; (p<0.001). In addition to reducing the risk of complications that are associated with allogeneic transfusion, postoperative blood salvage may offer benefits including reducing the need for allogeneic blood. Our study confirmed that postoperative collection and transfusion of drainaged blood is simple and safe method that significantly reduce the need for allogeneic transfusion in patients underwent total hip replacement. The blood collected and transfused postoperatively has lower values of red blood cells and normal values of potassium and acid base balance. The transfusion of this blood caused no complications in our patients.     

Changes in structure and metabolism in the m. vastus lateralis in monkeys after a space flight

Monkeys developed a significant reduction in size of the m. vastus lateralis' fast and slow fibres, the amount of protein in them remaining the same.     

Treatment of total sternal necrosis using the latissimus dorsi muscle flap

Complications after a median sternotomy incision, which is used currently in most cardiac and mediastinal surgical procedures, although infrequent, are serious. If sternal dehiscence follows median sternotomy, infection extends to vital underlying structures, exposing the anterior part of the heart and ascending aorta. Permanent hemorrhage, septic thrombosis, or septic perforation of prosthetic material demand soft-tissue coverage. In 5 patients with total sternum necrosis the retrosternal space was covered with a latissimus dorsi muscle flap in order to achieve stable protection of the exposed mediastinal organs.     

Comparison of protein expression in human deltoideus and vastus lateralis muscles using two-dimensional gel electrophoresis

We have used two-dimensional gel electrophoresis (2-DE) and mass spectrometry (MS) to study the expression of contractile and regulatory proteins in human vastus lateralis and deltoideus muscles, in order to understand protein turnover and isoform switching in muscles with the same fiber-type composition but different functional properties. We demonstrate a two- to six-fold overexpression of enzymes associated with glycolysis, the tricarboxylic acid cycle, oxidative phosphorylation, and substrate transport in vastus lateralis compared to deltoideus. Expression levels of contractile protein isoforms correlated to the proportion of slow-twitch fibers in deltoideus compared to vastus lateralis are consistent with the different contractile properties of the two muscles. Two proteins involved in free radical homeostasis were differentially expressed, suggesting a direct relationship between radical scavenging and the muscle function. The application of 2-DE and MS to studies of muscle physiology thus offers a more comprehensive assessment of the molecular determinants of muscle function than traditional approaches.     

Management of the hairline using a local flap in total reconstruction for microtia

In cases of microtia with a low hairline, the manner in which hair is removed from the reconstructed auricle must be taken into consideration. This is one of the most common but difficult problems with reconstruction for microtia. The authors describe a new technique that uses a simple regional flap to resolve this problem. The hair-bearing skin in the estimated auricular region and its covering are removed using a local flap from the hairless mastoid region. This is done in the first stage of auricular reconstruction, the costal cartilage grafting is done in the second stage, and elevation of the auricle is done in the last stage. In 38 auricles of 36 patients who were treated from 1993 to 1995, eight auricles of eight patients were treated with this technique. In all cases, the hairless flap healed well, without vascular stasis or skin necrosis. In addition, no complications from using this technique occurred in the later stages of auricular reconstruction. With this technique, the skin of the flap provides a good texture and color match to the auricle. In addition, the skin of the flap has good elasticity for the cutaneous pocket for cartilage grafting. The harvested area of the flap can be hidden behind the reconstructed auricle. The authors initially wondered whether the marginal scar of the transposed flap's position in the auricle would be conspicuous. However, all of the scar became inconspicuous because it was positioned in the scaphoid fossa.     

Measuring improvement following total hip and knee arthroplasty using the SF-36 Health Survey

The aim of this study was to evaluate the impact of total hip or knee arthroplasty upon quality of life in elderly patients. The study was carried out at the Clinic for Orthopaedic Surgery Lovran on 74 total hip arthroplasty and 70 total knee arthroplasty patients. All patients had completed the Medical Outcomes Study 36-Item Short Form in the week having preceded their surgery and then again postoperatively, 2 years after. The data obtained were statistically processed at the level of physical function, role limitations due to physical problems, role limitations due to emotional problems, social function, mental health, energy or vitality, pain and general health perception, and change in health. The primary total hip arthroplasty patients showed significant improvement at all levels measured. Similarly, the primary total knee arthroplasty patients expressed significant improvement according to all the parameters but the mental health assessment. Comparison of outcomes between the two assessment groups of patients resulted in slightly superior quality of life outcomes in total hip arthroplasty patients. It can be concluded that total hip or knee arthroplasty significantly enhances the health related quality of life in elderly patients.     

Reliability of an electrophoretic and image processing analysis of human skeletal muscle taken from m. vastus lateralis

The relative content of myosin heavy chain (MHC) isoforms IIb, IIa and I in human skeletal muscle taken from the m. vastus lateralis of 30 healthy male subjects was analysed using mini-gel electrophoresis. Repeated electrophoretic gels utilizing the same methods were produced for all subjects and the determination of MHC protein bands was performed using a digital scanner and National Institutes of Health (NIH) Image software and laser densitometry. A comparison between the NIH Image processing technique and laser densitometry revealed differences of 6.47%, 6.35% and 6.84% between these measurement techniques for MHC-IIb, -IIa and -I isoforms, respectively. The percentage technical error of measurement (TEM%) between electrophoretic gels was shown to be 19.1%, 17.8% and 14.2%, with regard to percentage of occurrence of MHC-IIb, -IIa and -I isoforms respectively. The variation in electrophoretic gel analyses was shown to be 5.7%, 7.3% and 5.5%, with regard to the percentage of MHC-IIb, -IIa and -I isoforms respectively. Intra-class correlations comparing NIH Image and laser densitometry produced r values in the range 0.38–0.63. Comparisons between and within gel analyses produced r values in the range 0.59–0.94 and 0.93–0.98, respectively. Analyses of variance revealed no significant differences (P < 0.05) between analysis techniques, between␣gels or within gels for the measurement of MHC-IIb, -IIa and -I isoforms. The inter-gel error between fibre subgroups was moderate for the two type-II MHC populations and less for type-I MHC; the intra-individual error in the measuring technique used for classifying the MHC-IIb, -IIa and -I protein bands was small. The results obtained in this investigation showed consistent trends which may reflect a false classification of the type-II MHC populations for the inter-gel and intra-individual analyses. The NIH Image software and digitizing process was shown to be a valid and reliable method for distinguishing between MHC protein bands of human skeletal tissue as separated by mini-gel electrophoretic techniques. Accepted: 6 January 1997     

Comparison of patient and surgeon expectations of total hip arthroplasty

Objectives

Analysis of discrepancies between patient and surgeon expectations before total hip arthroplasty (THA) should enable a better understanding of motives of dissatisfaction about surgery, but this question has been seldom studied. Our objectives were to compare surgeons'' and patients'' expectations before THA, and to study factors which affected surgeon-patient agreement.

Methods

132 adults (mean age 62.8+/−13.7 years, 52% men) on waiting list for THA in three tertiary care centres and their 16 surgeons were interviewed to assess their expectations using the Hospital for Special Surgery Total Hip Replacement Expectations Survey (range 0–100). Patients'' and surgeons'' answers were compared, for the total score and for the score of each item. Univariate analyses tested the effect of patients'' characteristics on surgeons'' and patients'' expectations separately, and on surgeon-patient differences.

Results

Surgeon and patient expectations'' mean scores were high (respectively 90.9+/−11.1 and 90.0+/−11.6 over 100). Surgeons'' and patients'' expectations showed no systematic difference, but there was little agreement on Bland and Altman graph and correlation coefficient was low. Patients had higher expectations than surgeons for sports. Patients rated their expectations according to trust in physician and mental quality of life, surgeons considered disability. More disabled patients and patients from a low-income professional category were often “more optimistic” than their surgeons.

Conclusion

Surgeons and patients often do not agree on what to expect from THA. More disabled patients expect better outcomes than their surgeons.     

Spatial EMG potential distribution pattern of vastus lateralis muscle during isometric knee extension in young and elderly men

The aim of the present study was to compare spatial electromyographic (EMG) potential distribution during force production between elderly and young individuals using multi-channel surface EMG (SEMG). Thirteen elderly (72-79 years) and 13 young (21-27 years) healthy male volunteers performed ramp submaximal contraction during isometric knee extension from 0% to 65% of maximal voluntary contraction. During contraction, multi-channel EMG was recorded from the vastus lateralis muscle. To evaluate alteration in heterogeneity and pattern in spatial EMG potential distribution, coefficient of variation (CoV), modified entropy and correlation coefficients with initial torque level were calculated from multi-channel SEMG at 5% force increment. Increase in CoV and decrease in modified entropy of RMS with increase of exerted torque were significantly smaller in elderly group (p < 0.05) and correlation coefficients with initial torque level were significantly higher in elderly group than in young group at moderate torque levels (p < 0.05). These data suggest that the increase of heterogeneity and the change in the activation pattern are smaller in elderly individuals than in young individuals. We speculated that multi-channel SEMG pattern in elderly individual reflects neuromuscular activation strategy regulated predominantly by clustering of similar type of muscle fibers in aged muscle.     

Functional reconstruction after a total maxillectomy using a fibula osteocutaneous flap with osseointegrated implants

The fibula osteocutaneous flap with osseointegrated implants was used for reconstruction of a total maxillectomy defect. We have achieved satisfactory reconstruction of three-dimensional facial structure, orbit support, and a functional prosthesis. Our procedure restored the patient's masticatory function of the maxilla and enabled good speech and a natural facial appearance. A very high quality of function was obtained without any complications, but long-term follow-up is necessary for maintenance of the implants.