Postoperative soft tissue defects in the ankle area : The etiology and methods of reconstruction

The risk is obvious for soft tissue complications after operative treatment of the Achilles tendon, calcaneal bone or after ankle arthroplasty. Such complications after malleolar fractures are, however, seldom seen. The reason behind these complications is that the soft tissue in this region is tight and does not allow much tension to the wound area after surgery. Furthermore the area of operation may be damaged by swelling after the injury, or can be affected by peripheral vascular disease. While complications in this area are unavoidable, they can be diminished. This study attempts to highlight the possible predisposing factors leading to complications in these operations and on the other hand, to determine the solutions to solve soft tissue problems in this region. The study consists of five papers. The first article is a reprint on the soft tissue reconstruction of 25 patients after their complicated Achilles tendon surgeries were analysed. The second study reviews a series of 126 patients after having undergone an operative treatment of calcaneal bone fractures and analyses the complications and possible reasons behind them. The third part analyses a series of corrections of 35 soft tissue complications after calcaneal fracture operations. The fourth part reviews a series of 7 patients who had undergone complicated ankle arthroplasties. The last article presents a series of post operative lateral defects of the ankle treated with a less frequently used distally based peroneus brevis muscle flap and analyses the results. What can be conducted from these studies is that in general, the results after the correction of even severe soft tissue complications in the ankle region are good. For the small defects around the Achilles tendon, the local flaps are useful, but the larger defects are best treated with a free flap. We found that a long delay from trauma to surgery and a long operating time were predisposing factors that lead to soft tissue complications after operatively treated calcaneal bone fractures. The more severe the injury, the greater the risk for wound complication. Surprisingly, the long-term results after infected calcaneal osteosyntheses were acceptable and the calcaneal bone seems to tolerate chronic infections very well if the soft tissue is reconstructed successfully. Behind the complicated ankle arthroplasties, unexpectedly high number of cases experiencing arteriosclerosis of the lower extremity was found. These complications lead to ankle fusion but can be solved with a free flap if the vascularity is intact or can be reconstructed. For this reason a vascular examination of the lower extremity arteries of the patients going to ankle arthroplasty is strongly recommended. Moreover postoperative lateral malleolar wound infections which typically create lateral ankle defects can successfully be treated with a peroneus brevis muscle flap covered with a free skin graft.

Discurso falso en los personajes femeninos de la novela griega

[EN] This paper examines how the female characters in Greek novels have recourse to false speech. Based on an analysis of female speech in Attic tragedy, which was one of the literary genres that exerted the greatest influence on speech parts of the novels, a study is conducted to find out which characters in the novel employ false speech and their purpose in doing so. Two types of false speech were identified: the defensive one, used by the female protagonists or by secondary characters of similar social and ideological status, and the offensive one, used by characters of lower rank, and blameworthy morality within the ideological love's frameword publicized through the novel.

Efeitos do uso de antiinflamatório e do exercício aeróbico sobre a regeneração tecidual e perfil biomecânico do tendão calcâneo de ratos após ruptura completa

Ruptura do tendão calcâneo é uma das lesões tendíneas mais frequentes. Embora a maioria dos trabalhos sugira que o exercício seja benéfico na cicatrização tendínea, não há consenso sobre o efeito do antiinflamatório neste contexto. Trabalhos experimentais tentam reproduzir lesão aguda deste tendão, em diferentes espécies animais. Neste estudo, descrevemos uma técnica de tenotomia completa do tendão calcâneo direito em ratos e, em seguida, avaliamos os efeitos do uso do antiinflamatório e do exercício aeróbico, isoladamente e em combinação, sobre a proliferação celular e o perfil biomecânico do tendão calcâneo, durante o processo de cicatrização após tenotomia. Estudo experimental com 156 ratos machos adultos, da raça Wistar, com idade média de 3 meses e peso médio de 300g. Após anestesia com tiopental e com auxílio da microscopia de luz, foi realizada incisão longitudinal posterior de cinco milímetros, em direção proximal, a partir da tuberosidade posterior do calcâneo da pata direita do rato. Foi feito corte transversal do tendão calcâneo, a sete milímetros da tuberosidade do calcâneo, com preservação do tendão plantar. Utilizamos as técnicas de Hematoxilina e Eosina, Picrosirius-red e Resorcina-fucsina de Weigert para avaliação da cicatrização tendínea e das fibras dos sistemas colágeno e elástico. Após a tenotomia, metade dos animais receberam tenoxicam intramuscular por 7 dias e no 8o dia iniciou-se protocolo de exercício em esteira na metade de cada grupo. Os ratos foram divididos aleatoriamente em 4 grupos de tratamento: A sem antiinflamatório E sem exercício (controle); B com antiinflamatório E com exercício; C sem antiinflamatório E com exercício; D com antiinflamatório E sem exercício. Os animais foram eutanasiados com 1, 2, 4 e 8 semanas após a tenotomia, para avaliação histológica pelo PCNA, e biomecânica através do teste de resistência à tração e da medida do ciclo locomotor. Foram realizados análise de variância, teste de Kruskal-Wallis e o método de Bonferroni, no programa R Project, versão 2.11.1. O tempo cirúrgico médio foi de 1 minuto e 24 segundos, sem complicações observadas até a 8a semana pós-operatória. Observamos proliferação celular e fibrilogênese com duas semanas, e diminuição da celularidade e das fibras elásticas na 8a semana, além de mudanças na organização estrutural do sistema colágeno. Encontramos pico da imunomarcação com PCNA na 2a semana em todos os grupos, exceto no grupo A, cujo pico aconteceu com 1 semana da tenotomia. Evidenciamos resistência à tração significativamente maior (p=0,02) nos ratos submetidos ao exercício, 8 semanas após ruptura. Nos grupos com antiinflamatório, observamos um ciclo locomotor mais estável durante todo o tempo avaliado. Consideramos a técnica cirúrgica experimental de tenotomia completa do tendão calcâneo, realizada com auxílio da microscopia de luz e preservação do tendão plantar, simples, rápida, com sinais de cicatrização tendínea normal e de fácil reprodução em ratos. O exercício aeróbico, iniciado precocemente após tenotomia completa do tendão calcâneo, é significativamente benéfico na sua recuperação biomecânica e o uso combinado com antiinflamatório confere maior estabilidade na marcha, o que pode proteger contra rerruptura tendínea em ratos

Variaciones termométricas en la planta del pie y piernas valorada en corredores antes y después de correr 30 km

La termometría es una técnica no invasiva que permite cuantificar los cambios en la temperatura cutánea y evaluarla de forma cuantitativa. El aumento significativo de la temperatura puede indicar la existencia de patología. Se ha demostrado que la actividad muscular induce procesos de transferencia de calor entre los músculos y las capas superficiales de tejido. En este estudio queremos cuantificar los cambios de temperatura que se producen en los músculos del pie y miembro inferior tras una carrera de 30 km, para ello hemos utilizado una cámara termográfica de alta resolución. Contamos con la colaboración voluntaria de 32 sujetos sanos a los que procedimos a tomar fotografías de la planta del pie, parte anterior de la pierna, parte posterior de la pierna, parte anterior del muslo y parte posterior del muslo en dos etapas, primero antes de la carrera y segunda toma después de la carrera de 30 km, de esta manera pudimos valorar si había o no variación de temperatura en las zonas seleccionadas. Tras el análisis de los datos obtenidos encontramos significativas variaciones térmicas en Talón, cabeza primer metatarsiano, cabeza segundo metatarsiano, cabeza tercer metatarsiano, cabeza cuarto metatarsiano, cabeza quinto metatarsiano, apófisis estiloides quinto metatarsiano, arco longitudinal interno, maléolo interno, maléolo externo, peroneo lateral largo, vasto interno, vasto externo, recto femoral, tensor de la fascia lata, inserción cuádriceps, gemelo interno, tendón de Aquiles y Biceps femoral.

Literatura y acto: Aquiles, el regreso a la batalla

Greek literature was used from early times with educational purposes, Greek heroes presented were considered as paradigms to follow. However, human acts burst beyond reason and the stories told have little effect on the decisions of the receptor. The aim of this article is to review the character of Achilles in the Iliad, because for him to no avail gifts, friends, much less a narration by his preceptor Phoenix to depose his anger and return to the battlefield to assist his friends.

La cultura homérica en la Escenografía del Seiscientos: "Il Greco in Troia" y "La caduta del regno dell´Amazzoni"

Sería imposible hacer una enumeración de festejos, espectáculos y representaciones teatrales, que a lo largo de la época moderna, tuvieron como argumento las historias narradas por la literatura homérica. Incontables, pero todas ellas buscaban el don de la elocuencia que tenían desde que en la Antigüedad empezaron a reeditarse. Apenas un iglo después de la recopilación de relatos orales que quedaron hilvanados bajo los títulos de la Iliada y la Odisea –si se acepta la autoría de ese personaje mítico que fue Homero en torno al siglo VIII antes de Cristo–, tiranos y oligarcas atisbaron de forma visionaria las posibilidades que aportaban las tramas en las que se vieron envueltos dioses y héroes. La mitología olímpica no sólo sirvió al propósito de la unificación panhelénica de la nación de naciones que era Grecia, en torno a un mundo de creencias común en el marco de los grandes santuario, sino que además, las vicisitudes de los principales personajes, como Paris, Aquiles, Héctor, Ulises, Pentesilea, Eneas, Agamenón, Andrómaca, Casandra y Helena, proporcionaron un repertorio de modelos de conducta y un protocolo ceremonial en sociedad extremadamente útil. Piedad, fidelidad, excelencia, belleza, sumisión, virtudes morales que habían de “adornar” por igual a gobernantes y a ciudadanos, garantizaban un nuevo orden en la Hélade, constituyendo asimismo las notas distintivas con respecto a los anquilosados y monolíticos Imperios hegemónicos en la zona de Oriente Próximo, Egipcio y Babilónico o Persa, respectivamente. Se propone el análisis de la incidencia iconológica de tales asuntos a partir de la revisión escenográfica de dos libretos para dos representaciones teatrales italianas de finales del Seicento, de los que se encuentran sendos ejemplares en la Biblioteca Nacional de Madrid: Il Greco in Troia y La caduta del regno dell´amazzone.

Development of a bovine collagen-apatitic calcium phosphate cement for potential fracture treatment through vertebroplasty

The aim of this study was to examine the potential of incorporating bovine fibres as a means of reinforcing a typically brittle apatite calcium phosphate cement for vertebroplasty. Type I collagen derived from bovine Achilles tendon was ground cryogenically to produce an average fibre length of 0.96 ± 0.55 mm and manually mixed into the powder phase of an apatite-based cement at 1, 3 or 5 wt.%. Fibre addition of up to 5 wt.% had a significant effect (P = 0.001) on the fracture toughness, which was increased by 172%. Adding =1 wt.% bovine collagen fibres did not compromise the compressive properties significantly, however, a decrease of 39-53% was demonstrated at =3 wt.% fibre loading. Adding bovine collagen to the calcium phosphate cement reduced the initial and final setting times to satisfy the clinical requirements stated for vertebroplasty. The cement viscosity increased in a linear manner (R = 0.975) with increased loading of collagen fibres, such that the injectability was found to be reduced by 83% at 5 wt.% collagen loading. This study suggests for the first time the potential application of a collagen-reinforced calcium phosphate cement as a viable option in the treatment of vertebral fractures, however, issues surrounding efficacious cement delivery need to be addressed. © 2012 Acta Materialia Inc.

A role of autophagy in PTP4A3-driven cancer progression

Autophagy, a "self-eating" cellular process, has dual roles in promoting and suppressing tumor growth, depending on cellular context. PTP4A3/PRL-3, a plasma membrane and endosomal phosphatase, promotes multiple oncogenic processes including cell proliferation, invasion, and cancer metastasis. In this study, we demonstrate that PTP4A3 accumulates in autophagosomes upon inhibition of autophagic degradation. Expression of PTP4A3 enhances PIK3C3-BECN1-dependent autophagosome formation and accelerates LC3-I to LC3-II conversion in an ATG5-dependent manner. PTP4A3 overexpression also enhances the degradation of SQSTM1, a key autophagy substrate. These functions of PTP4A3 are dependent on its catalytic activity and prenylation-dependent membrane association. These results suggest that PTP4A3 functions to promote canonical autophagy flux. Unexpectedly, following autophagy activation, PTP4A3 serves as a novel autophagic substrate, thereby establishing a negative feedback-loop that may be required to fine-tune autophagy activity. Functionally, PTP4A3 utilizes the autophagy pathway to promote cell growth, concomitant with the activation of AKT. Clinically, from the largest ovarian cancer data set (GSE 9899, n = 285) available in GEO, high levels of expression of both PTP4A3 and autophagy genes significantly predict poor prognosis of ovarian cancer patients. These studies reveal a critical role of autophagy in PTP4A3-driven cancer progression, suggesting that autophagy could be a potential Achilles heel to block PTP4A3-mediated tumor progression in stratified patients with high expression of both PTP4A3 and autophagy genes.

The Pindaric poetry of Cruz e Silva and the Neoclassical revival among Lusitanian national heroes

António Dinis da Cruz e Silva, member of Arcádia Lusitana, the literary academy he helped to found, introduced the Pindaric ode to the Portuguese literature of the neoclassical period (18th century). This poet imitates the triadic form and the mythological nature of Pindar’s encomiastic poetry, in order to celebrate the deeds of reputed historical figures from the national context, such as sailors, captains, politicians, and even the king himself. As in Pindar’s poetry, the mythological excursus holds an important part in Cruz e Silva’s Pindaric poetry. Winners of athletic games are acclaimed through allusion to the ancient heroes. Likewise, the heroes of the Portuguese history see themselves turned into immortals, since their deeds are reported as comparatively greater than those of Homeric warriors. Among the 44 Cruz e Silva’s Pindaric odes, 18 rewrite the myth of the Trojan War, from its beginnings with Eris (Odes I-II) to its outcome with the imperishable fame of the most conspicuous Homeric fighters (Ode XLII). These 18 compositions (re)tell, in a neoclassical style, the main scenes and themes of the Iliad and Odyssey, alluding directly to their heroes’ deeds. Achilles’ wrath and Hector’s death are topics repeatedly brought up in Cruz e Silva’s Pindaric poetry as models of courage and patriotism for national heroes. This chapter offers a discussion of Cruz e Silva’s neoclassical representation of the Trojan War. To this effect, an interdisciplinary approach is adopted, showing how the Portuguese poet handles the mythological material from Homer and Pindar. In this way, he initiated in 18th-century Portuguese literature a new literary genre, the Pindaric ode. By dealing with Poetry and History, Cruz e Silva perpetuated the life and fame of national heroes long after their deaths.

Assessment by doppler ultrasound of entheseal lesions in spondyloarthritis : a longitudial study to determine structural damage and disease activity lesions

RESUMO: Enthesitis is the hallmark of spondyloarthritis (SpA), and is observed in all subtypes. Wide information on SpA abnormalities, including synovitis, tendinitis and enthesitis, can be efficiently perceived by Doppler ultrasound. Furthermore, several studies on imaging of enthesis showed that imaging techniques are better than clinical examination to detect enthesis alterations; and vascularized enthesitis detected by Doppler ultrasound appears to be a valuable diagnostic tool to confirm SpA diagnosis. However, data published until now concerning entheseal elementary alterations that characterize SpA enthesitis (enthesis inflammatory activity) or enthesopathy (permanent structural changes) reflect rather the authors’ empiric opinion than a methodological validation process. In this sense it seems crucial to identify elementary entheseal lesions associated with activity or damage, in order to improve monitoring and treatment response in SpA patients. The development of better assessment tools is today a challenge and a need in SpA. The first study of this thesis focused on the analysis of the reliability of inter-lector and inter-ultrasonography equipment of Madrid sonography enthesitis index (MASEI). Fundamental data for the remaining unrolling project validity. In the second and third studies we concerned about two entheseal elemental lesions: erosions and bursa. In literature erosions represent a permanent structural damage, being useful for monitoring joint injury, disease activity and therapeutic response in many rheumatic diseases; and to date, this concept has been mostly applied in rheumatoid arthritis (RA). Unquestionably, erosion is a tissue-related damage and a structural change. However, the hypothesis that we decided to test was if erosions represent a permanent structural change that can only grow and worsen over time, as occurs in RA, or a transitory alteration. A longitudinal study of early SpA patients was undertaken, and the Achilles enthesis was used as a model. Our results strongly suggested that previously detected erosions could disappear during the course of the disease, being consistent with the dynamic behavior of erosion over time. Based on these striking results it seems reasonable to suggest that the new-bone formation process in SpA could be associated with the resolution of cortical entheseal erosion over time. These results could also be in agreement with the apparent failure of anti-tumor necrosis factor (TNF) therapies to control bone proliferation in SpA; and with the relation of TNF-α, Dickkopf-related protein 1 (Dkk-1) and the regulatory molecule of the Wnt signaling pathway in the bone proliferation in SpA. In the same model, we then proceeded to study the enthesis bursa. Interestingly, the Outcome Measures in Rheumatology Clinical Trials (OMERACT) enthesopathy definition does not include bursa as an elementary entheseal lesion. Nonetheless, bursa was included in 46% of the enthesis studies in a recently systematic literature review, being in agreement with the concept of “synovio-entheseal complex” that includes the link between enthesitis and osteitis in SpA. It has been clarified in recent data that there is not only a close functional integration of the enthesis with the neighboring bone, but also a connection between enthesitis and synovitis. Therefore, we tried to assess the prevalence and relevance of the bursa-synovial lesion in SpA. Our findings showed a significant increase of Achilles bursa presence and thickness in SpA patients compared to controls (healthy/mechanical controls and RA controls). These results raise awareness to the need to improve the enthesopathy ultrasonographic definition. In the final work of this thesis, we have explored new perspectives, not previously reported, about construct validity of enthesis ultrasound as a possible activity outcome in SpA. We performed a longitudinal Achilles enthesis ultrasound study in patients with early SpA. Achilles ultrasound examinations were performed at baseline, six- and twelve-month time periods and compared with clinical outcome measures collected at basal visit. Our results showed that basal erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are higher in patients with Doppler signal in enthesis, and even that higher basal ESR, CRP and Ankylosing Spondylitis Disease Activity Score (ASDAS) predicted a higher Doppler signal (an ultrasound alteration accepted as representative of inflammation) six months later. Patients with very high disease activity assessed by ASDAS (>3.5) at baseline had significantly higher Achilles total ultrasound score verified at the same time; and ASDAS <1.3 predicted no Doppler signal at six and twelve months. This seems to represent a connection between classical biomarkers and clinical outcomes associated with SpA activity and Doppler signal, not only at the same time, but also for the following months. Remarkably, patients with inactive disease (ASDAS < 1.3) at baseline had no Doppler signal at six and twelve months. These findings reinforce the potential use of ultrasound related techniques for disease progression assessment and prognosis purposes. Intriguingly, Ankylosing Spondylitis Disease Activity Index (BASDAI) didn’t show significant differences between different cut-offs concerning ultrasound lesions or Doppler signal, while verified with ASDAS. These results seem to indicate that ASDAS reflects better than BASDAI what happens in the enthesis. The work herein discussed clearly shows the potential utility of ultrasound in enthesis assessment in SpA patients, and can be important for the development of ultrasound activity and structural damage scores for diagnosis and monitoring purposes. Therefore, local promotion of this technique constitutes a medical intervention that is worth being tested in SpA patients for diagnosis, monitoring and prognosis purposes.

Device-specific weighted T-score for two quantitative ultrasounds: operational propositions for the management of osteoporosis for 65 years and older women in Switzerland.

The World Health Organization (WHO) criteria for the diagnosis of osteoporosis are mainly applicable for dual X-ray absorptiometry (DXA) measurements at the spine and hip levels. There is a growing demand for cheaper devices, free of ionizing radiation such as promising quantitative ultrasound (QUS). In common with many other countries, QUS measurements are increasingly used in Switzerland without adequate clinical guidelines. The T-score approach developed for DXA cannot be applied to QUS, although well-conducted prospective studies have shown that ultrasound could be a valuable predictor of fracture risk. As a consequence, an expert committee named the Swiss Quality Assurance Project (SQAP, for which the main mission is the establishment of quality assurance procedures for DXA and QUS in Switzerland) was mandated by the Swiss Association Against Osteoporosis (ASCO) in 2000 to propose operational clinical recommendations for the use of QUS in the management of osteoporosis for two QUS devices sold in Switzerland. Device-specific weighted "T-score" based on the risk of osteoporotic hip fractures as well as on the prediction of DXA osteoporosis at the hip, according to the WHO definition of osteoporosis, were calculated for the Achilles (Lunar, General Electric, Madison, Wis.) and Sahara (Hologic, Waltham, Mass.) ultrasound devices. Several studies (totaling a few thousand subjects) were used to calculate age-adjusted odd ratios (OR) and area under the receiver operating curve (AUC) for the prediction of osteoporotic fracture (taking into account a weighting score depending on the design of the study involved in the calculation). The ORs were 2.4 (1.9-3.2) and AUC 0.72 (0.66-0.77), respectively, for the Achilles, and 2.3 (1.7-3.1) and 0.75 (0.68-0.82), respectively, for the Sahara device. To translate risk estimates into thresholds for clinical application, 90% sensitivity was used to define low fracture and low osteoporosis risk, and a specificity of 80% was used to define subjects as being at high risk of fracture or having osteoporosis at the hip. From the combination of the fracture model with the hip DXA osteoporotic model, we found a T-score threshold of -1.2 and -2.5 for the stiffness (Achilles) determining, respectively, the low- and high-risk subjects. Similarly, we found a T-score at -1.0 and -2.2 for the QUI index (Sahara). Then a screening strategy combining QUS, DXA, and clinical factors for the identification of women needing treatment was proposed. The application of this approach will help to minimize the inappropriate use of QUS from which the whole field currently suffers.

Poésies d'« ALLAIN CHARRETIER », « PIERRE DE NESSON », « JEHAN CASTEL », « MICHAULT », « GEORGE » et « PIERRE CHASTELLAIN », « MOULINET », [MARTIAL D'AUVERGNE].

Contient : 1 « Les Faiz maistre Allain Charretier », savoir : ; 2 « Louenge et foy et honmaige faicte à la Vierge Marie par maistre Pierre de Nesson » ; 3 « Le Specule des pecheurs », par « Jehan Castel » (fol. 331), — « Requeste de Castel adroissant à monseigneur de Gaucourt ». (fol. 345) ; 4 « Le Passe temps Michault » ; 5 « Le Debat d'Hector et d'Achilles », par « George » [Chastelain] ; 6 « Le Contrepasse temps Michault », par « Pierre Chastellain » ; 7 « Le Temple de Mars », par « Moulinet » ; 8 « L'Amant rendu Cordelier à l'observance d'amours » [par Martial d'Auvergne] ; 9 Pièces anonymes :

Recueil de prose et de vers concernant Alexandre, Annibal et Scipion, Hector et Achille, Dagobert, Clovis II et Charles VIII, Philippe le Beau, roi d'Espagne, les comtes de Dammartin.

Contient : 1 Histoire de Dagobert et de son fils Louis (Clovis II), et faits et gestes de Assaillant, comte de Dammartin, et de son fils Guérard, en 12 chapitres. Table des chapitres. (Fol. 1.) Le premier chapitre commence par : « En l'an de l'incarnation Nostre Seigneur six cens trante, Dagobert, roy de France... ». (Fol. 4 v°.) Le douzième chapitre finit par : «... et confundirent les mecréans en exaltant tousjours la loy de Nostre Seigneur ». (Fol. 64 v°) ; 2 Dispute entre Alexandre, Annibal et Scipion, au sujet de la prééminence, et jugement de Minos ; 3 Pièce de vers en l'honneur d'une dame ; 4 « L'Epytaphe de Hector » ; 5 « L'Espytaphe d'Achilles » ; 6 Complainte sur la mort de Charles VIII, incomplète du commencement. Les premiers vers sont ; 7 « Epitaphe du roy Charles huitiesme de ce nom » ; 8 Sur la mort de Philippe Ier d'Autriche, roi d'Espagne, mort le 25 sept. 1506, agé de 28 ans ; 9 Note sur le mariage, le 1er sept. 1538, de « noble homme Françoys d'Orléans, seigneur de Rouzay, filz de ... Françoys d'Orléans, grenetier d'Issoidum », et de « Jehanne Boutet », et sur la naissance de leurs enfants