A novel approach to treat ischemic tissues by using gene therapy has recently been introduced on the basis of the angiogenic potential of certain growth factors. The authors investigated the effect of adenovirus-mediated gene therapy with vascular endothelial growth factor (VEGF) delivered into the subdermal space to treat compromised skin flaps. For this purpose, the epigastric skin flap model in rats, based solely on the right inferior epigastric vessels, was used. Thirty male Sprague-Dawley rats were divided into five groups of six rats each. Viral transfection with 108 plaque-forming units was performed 2 days before the epigastric flap elevation. Rats received subdermal injections of adenovirus encoding VEGF (Ad-VEGF) or green fluorescent protein (Ad-GFP) as treatment control. Another set of animals (n = 6) received no injections and were designated as control. To determine whether site of injection had an impact on flap viability, injections were given into the predicted local ischemic area (Ad-VEGF local, n = 6; Ad-GFP local, n = 6) and into the midline of the flap (Ad-VEGF midline, n = 6; Ad-GFP midline, n = 6). A flap measuring 8 × 8 cm was outlined on the abdominal skin extending from the xiphoid process proximally and the pubic region distally, to the anterior axillary lines bilaterally. Then, the epigastric flap was elevated as an island on the right inferior epigastric vessels and sutured back to its bed. Flap viability was evaluated at 7 and 14 days after the first operation. The epigastric flaps were scanned to the computer and areas of hypoxic and/or necrotic zones relative to total flap surface area were measured and expressed as percentages by using Image Pro Plus software. Specimens were taken for histologic evaluation at day 14 before the animals were killed. Combined area of necrotic and hypoxic zones as well as necrotic zone were decreased to 9.7 ± 1.4 percent and 1.4 ± 0.9 percent in Ad-VEGF local, and 11.8 ± 1.9 percent and 3.5 ± 1.64 percent in Ad-VEGF midline compared with the control and Ad-GFP treatment groups (control, 23 ± 3.6 percent and 20.1 ± 3.3 percent; Ad-GFP local, 24.8 ± 4.8 percent and 16.2 ±5.9 percent; and Ad-GFP midline, 23.4 ± 6.9 percent and 19.5 ± 7.7 percent; p <0.05). Histologic evaluation by light microscopy failed to demonstrate any quantitative difference in vascularity of skin flaps between the treatment groups. In this study, the authors demonstrated that adenovirus-mediated gene therapy using VEGF enhanced epigastric skin flap survival, as confirmed by the significant reduction in combined area of necrotic and hypoxic zones of the flap. Compared with the control, both local and midline subdermal injections of Ad-VEGF showed improvement in overall flap survival by 57.9 and 48.7 percent, respectively. The results of this study raise the possibility of using adenovirus-mediated therapeutic angiogenesis for safer flap surgery in high-risk patients. (Plast. Reconstr. Surg. 109: 1986,2002.)

Proprioception is an essential part of shoulder stability and neuromuscular control. The purpose of the study was the development of a precise system of shoulder proprioception assessment in the active mode (Propriometr). For that purpose, devices such as the electronic goniometer and computer software had been designed. A pilot study was carried out on a control group of 27 healthy subjects, the average age being 23.8 (22–29) in order to test the system. The result of the assessment was the finding of the error of active reproduction of the joint position (EARJP). EARJP was assessed for flexion, abduction, external and internal rotation. For every motion, reference positions were used at three different angles. The results showed EARJP to range in 3–6.1°. The proprioception evaluation system (propriometr) allows a precise measurement of active joint position sense. The designed system can be used to assess proprioception in both shoulder injuries and treatment. In addition, all achieved results of normal shoulders may serve as reference to be compared with the results of forthcoming studies.

An experimental study was conducted to investigate the potential use of intravascular gene therapy with adenovirus-mediated (Ad) vascular endothelial growth factor (VEGF) or angiopoietin-l (Ang-1) for the enhancement of muscle flap perfusion and to evaluate the effect of therapy on microcirculatory hemodynamics and microvascular permeability in vivo by using a cremaster muscle flap model in the rat. The cremaster tube flap was left intact after isolation of the pudo-epigastric pedicle. A total of 90 male Sprague-Dawley rats were divided into five groups of 18 each, according to the type of intraarterial treatment. Control flaps received phosphate-buffered saline. Group 2 (the control gene encoding green fluorescent protein, Ad-GFP) served as the adenovirus control. In Groups 3, 4, and 5, flaps were pretreated with Ad-VEGF, Ad-Ang-1, and Ad-Ang-1 + Ad-VEGF, respectively. Flaps were preserved in a subcutaneous pocket in the hindlimb for evaluation of functional capillary density and microvascular permeability indices at 3, 7, and 14 days by intravital microscopy system. At day 7 and 14, Ad-VEGF, Ad-Ang-1, and combined treatment groups showed significantly higher numbers of capillary densities when compared with control and Ad-GFP groups (p < 0.05). At day 14, Ad-VEGF was the superior treatment group compared with Ad-Ang-1 and Ad-VEGF + Ad-Ang-1 (p < 0.05). Overall, there was a linear increase in the number of functional capillaries in all treatment groups (p < 0.05). At day 3 after Ad-Ang-l therapy, a significantly lower permeability index was found when compared with Ad-VEGF + Ad-Ang-1 and Ad-VEGF alone treatment (p < 0.05). At day 7, the Ad-VEGF group had the highest score of permeability index compared with control, combined, and Ad-Ang-1 groups (p < 0.05). Histologic evaluation of muscle flaps demonstrated mild focal inflammation. There was evidence of mild vasculitis in all flaps except control muscles. Intravascular angiogenic therapy with Ad-VEGF or Ad-Ang-1 was technically feasible, as demonstrated by expression of the control gene, GFP, along the vascular tree. All treatment groups increased perfusion of the muscle flap over a period of 14 days, indicating a long-lasting effect of gene therapy. Ang-1 alone or in combination with VEGF was as effective as VEGF alone in augmenting muscle perfusion with more stable vessels 1 week after gene therapy.

Purpose The purpose of the study was clinical and advanced biomechanical evaluation of shoulder function with respect to rotator cuff (RC) integrity following repair. Methods This was a retrospective study of 111 cases with solid single row rotator cuff repair and a minimal one-year follow-up. The RC repair was performed as an open procedure in 42 patients, arthroscopically assisted in 34 and fully arthroscopic in 48 cases. Evaluation protocol included ultrasound evaluation of the RC integrity, clinical evaluation using shoulder scores and advanced biomechanical evaluation (isometric and the isokinetic strength testing). Results Ultrasound evaluation revealed complete retear in 16 %, partial retear in 10 % and intact repair in 74 % of the cases. Isometric testing of flexion and abduction had shown that shoulders with complete retear were weaker by 45 % compared to those with full tendon healing. Isokinetic testing revealed 29–43 % deficits in peak external rotation torque comparing complete retear vs. normal healing. Patients’ ability to generate shoulder power and withstand a load proved to be lower in circumstances of a complete lack of healing (40–43 % and 34–55 %, respectively). Partial retears did not have a negative impact on the biomechanical properties of shoulders. Surprisingly, there were no significant differences in the shoulder scores related to the quality of healing. In terms of patient satisfaction the results were good and the patients declared themselves better in all cases, no matter what quality of healing had been recorded ultimately. Conclusions According to the results of this research rotator cuff integrity after open or arthroscopic repair does not seem to affect clinical scores. Recurrent tears may result in lower muscle performance in terms of active motion, strength and endurance. Advanced shoulder testing may be essential in assessing the patients’ ability to return to sports or heavy labour.