Vascular filling and protein extravasation in three varieties of vascularized venous nerve grafts

The purpose of this study was to compare the microcirculation perfusion and plasma-protein extravasation in varieties of venous nerve grafts. Venous nerve grafts were created from the left median nerve and brachial vein of the rabbit. The vein was interposed between (a) brachial artery to brachial artery (AVA); or (b) brachial artery to proximal cephalic vein (AVV); or (c) brachial vein to brachial vein (VVV). A standard, vascularized, nerve graft was created in the opposite limb, to serve as a control, and the untouched sciatic nerve served as a second control. Microcirculation perfusion and permeability of endoneurial vessels were evaluated using intravenously-injected albumin labelled with Evans blue dye (EBA) as a fluorescent tracer within 1 hr after surgery. Six hours after surgery, the nerves were removed and evaluated for tracer content and distribution. Extravasation of EBA was extensive in both AVA and AVV forms of the venous nerve graft, suggesting good perfusion but showing significant protein leakage and edema. VVV, on the other hand, had only slight extravasation, comparable to untouched sciatic nerves. Although the number of vessels filled with blood in the VVV was 69 percent of the vascularized nerve graft, the lack of marked extravasation may make it the venous nerve graft of choice.

A transverse skin incision approach for decompression of pronator teres syndrome

Pronator teres syndrome is a compressive neuropathy of the median nerve in the proximal part of the forearm and distal part of the arm. The outcome of surgical decompression is occasionally unsatisfactory because of a poor scar. We present the use of a transverse skin incision that allows adequate exploration and decompression distally and proximally, beneath the subcutaneous tissue beyond the volar elbow crease.

Microvascular reconstruction of the foot: weight-bearing patterns, gait analysis, and long-term follow-up

Between 1980 and 1989, 46 free-tissue transfers (32 skin flaps, 14 muscle flaps) were performed in 44 patients for foot reconstruction. Patient age averaged 25.8 years (range 2 to 74 years). Length of follow-up averaged 43 months. Flap survival rate was 96 percent. Debulking was done in 16 skin and 8 muscle flaps. The ulceration rate in 25 patients with weight-bearing flaps was 32 versus 11 percent in 19 patients with non-weight-bearing flaps. Time before ambulation averaged 6.4 months following weight-bearing reconstruction and 4.5 months following non-weight-bearing reconstruction. All patients with either abnormal foot-mat diagrams or major gait abnormalities had significant underlying radiologic foot abnormalities or nerve injuries. We conclude that both skin and muscle free flaps frequently need secondary debulking procedures to improve function. The ulceration rate tends to be higher in weight-bearing flaps than in non-weight-bearing flaps. Underlying bony architecture and nerve function affected weight-bearing patterns and gait more than type of wound coverage.

Regeneration following rejection of peripheral nerve allografts of rats on withdrawal of cyclosporine

Sequential changes in the sciatic nerve function and morphology were evaluated in transplanted nerve allografts from ACI-RT1a into Lewis RT1I rats after withdrawal of cyclosporine, which had been administered subcutaneously daily (5 mg/kg) for 12 weeks. Experimental groups were established as follows: (1) allograft with cyclosporine (evaluated and sacrificed at 12, 14, 16, 20, 24, and 36 weeks, 10 rats at each week), (2) allograft without cyclosporine (12 and 24 weeks, 10 rats at each week), (3) isograft with cyclosporine (12 and 24 weeks, 6 rats at each week), and (4) isograft without cyclosporine (12 and 24 weeks, 10 rats at each week). Regeneration was evaluated through walking track analysis, electrophysiologic studies, weight of the anterior tibial muscle, and axon counts, diameter, and myelin thickness. Regeneration was observed through 14 weeks after grafting; by 16 weeks, all rats had demonstrated a clear rejection phase, but regeneration indices then recovered quickly by 24 weeks. Electron microscopy of both the graft and distal nerve suggested that both Schwann cells and axons were affected by the rejection phenomenon. Allografts without cyclosporine showed inferior regeneration histologically at 24 weeks. Morphologically, allografts were equivalent to isografts treated with cyclosporine at 24 weeks. Although nerve allografts are rejected after cyclosporine withdrawal, they may still serve as effective nerve conduits.

A modified extensor carpi ulnaris tenodesis with the Darrach procedure

Fourteen patients with pain and limited forearm rotation were treated with a modified Darrach procedure involving a distally based slip of the extensor carpi ulnaris tendon. Seven patients had Colles' fractures, four had rheumatoid arthritis, and three had primary osteoarthritis of the distal radioulnar joint. Patients were assigned to one of two groups: rheumatoid arthritis or Colles' fracture/osteoarthritis. The average age was 50 years. Follow-up averaged 54 months (range, 12 to 96 months). The average amount of ulnar resection was 10 mm (range, 6 to 20 mm). In the Colles' fracture/osteoarthritic group, average grip strength (a percentage of the uninvolved hand) improved from 26% preoperatively to 74% postoperatively, and in the rheumatoid arthritis group it improved from 67% to 144%. Distal ulnar instability of the dorsal side was not observed on x-ray examination. Patients were satisfied with pain relief, and all returned to their original work.

A microcomputer-based whole-body counter for personnel routine monitoring

The paper describes a cost-effective NaI(Tl) whole-body counter developed for routine examinations of worker intakes at an isotope production facility. Signal processing, data analysis and system operation are microcomputer-controlled for minimum human interactions. The pulse height analyzer is developed as an microcomputer add-on card for easy manipulation. The scheme for radionuclide analysis is aimed for fast running according to a knowledge base established from background samples and phantom experiments in conjunction with a multivariate regression analysis. Long-term stability and calibration with standards and in vivo measurements are reported.

Thumb replantation: survival factors and re-exploration in 122 cases

We analyzed 122 cases of replantation following complete amputation of the thumb and correlated various factors with rates of survival. The overall survival rate of thumb replantation was 71%. The type of amputation markedly affected survival rate. In minimally damaged amputations, the time period from injury to the start of surgery was the only significant factor related to survival. Other factors such as age, smoking history, amputation level, the number of vessels reconstructed and the method used did not relate statistically to survival. With avulsion amputations, the survival rate of replantation at and proximal to the MP joint was significantly better than replantation distal to the MP joint. 20 thumbs required re-exploration for vascular compromise; nine of these were salvaged (45%).

Complications and results of scapho-trapezio-trapezoid arthrodesis

Forty cases of scapho-trapezio-trapezoid (STT) arthrodesis were reviewed. Indications for the procedure included rotatory subluxation of the scaphoid (30 patients) and STT arthrosis (ten patients). Follow-up time averaged 41 months. Ten patients (25%) required 13 additional procedures: operations for nonunion or a fracture of the distal radius after bone harvesting, partial radial styloidectomy, first carpometacarpal joint arthroplasty, and wrist arthrodesis. Complications without surgeries were seen in several cases: pin-tract infection, sympathetic dystrophy, delayed union treated with brace, and radial nerve irritation. Overall, complications were observed in 21 patients (53%), some having more than one complication. Degenerative arthritis at joints surrounding the STT mass was suspected based on roentgenograms in five cases. Twenty-three patients (58%) became pain free or had minimal pain with a limited arc of motion. Twenty of 34 patients (59%) returned to their regular work or the same job, and 27 (68%) reported good to excellent results. Although STT arthrodesis can provide a painless wrist with a limited arc of motion in most patients, complications are frequent.

Long-term results of denervation of the wrist joint for chronic wrist pain

The results have been evaluated of 29 patients who had wrist denervation for chronic wrist pain between 1979 and 1987. Follow-up ranged from 22 to 86 months (mean 51 months). 17 patients had denervation without a concurrent procedure. Of these, 12% became pain-free and 71% had pain with all activities or had additional surgery; 24% said they were satisfied with their treatment. The results were worse in those who had partial denervation than those who had total denervation. 12 patients had denervation performed concurrently with another pain-relieving procedure. Denervation alone was not reliable in resolving chronic wrist pain.

Blood flow and tissue survival in the rabbit venous flap

The extent of venous flow, revascularization, local fluid imbibition, and metabolic status was evaluated in an experimental venous flap model. Thirty-six rabbits divided into six groups of six rabbits each had a 3.5 x 2.5 cm venous flap elevated along the thoracoepigastric vein, connected only by its proximal and distal vein, and sutured back. A composite graft of the same size was created on the contralateral side. Venous flaps survived 14 days, while composite grafts consistently did not. The vascular network was partially filled with fluorescein tracer within an hour after flap creation, even with an underlying Silastic sheet. Filling improved over several days, consistent with rapid revascularization. Composite grafts showed no immediate filling and delayed revascularization. Venous flow was apparently insufficient to enhance metabolism, since both glucose and lactate levels were equivalent between venous flaps and composite grafts. This supports the concept that an enhanced revascularization may be the primary mechanism of survival for venous flaps.

Pre-operative factors and treatment outcome following carpal tunnel release

The outcome of carpal tunnel release was evaluated retrospectively in 60 hands of 53 patients followed for six to 33 months (median ten months). Outcome was considered good in 27% (pain, weakness, and numbness were essentially resolved); fair in 42% (most of the symptoms improved); and poor in 32% (symptoms persisted or worsened). Patients whose pre-operative work activity was considered physically strenuous were associated with a slightly but significantly poorer outcome (60% good or fair) compared to those in light work or with no employment (89% good or fair). Proportionately fewer patients returned to their original work when they previously engaged in strenuous activity, ranging from 27% for those using air guns to 80% in light work. It appears that the highest chance of a poor outcome from carpal tunnel release occurs in patients who have either associated symptoms of thoracic outlet syndrome or physically strenuous work activities.

Vascularized joint transfers. Indications and results

Vascularized joint transfer can be beneficial in restoring joint function and maintaining growth. It is sometimes indicated in patients with painful post-traumatic arthritis, post-traumatic joint instability, and post-traumatic deformity. The best indication for this procedure is in children whose joint injury is associated with damage to growth plates in any of the digits; however, the complications associated with this procedure should not be overlooked. Extensor lag is common. This complication may be prevented during the surgical procedure by using a step-cut osteotomy to preserve the insertion of the extensor tendon, resecting the volar plate of the finger, harvesting the transferred joint with enough length to keep the extensor tendon tight, and placing the transferred joint in a maximally extended position to counteract the flexible trend of the toe joints. We believe this procedure holds promise for the future. Further improvement in surgical technique and clarification of its indications will likely enhance overall results.

X-ray evaluation of radial shortening for Kienböck's disease

The effect of inclination of the distal radius to subsequent lunate collapse is controversial. Therefore we evaluated the postoperative x-ray course of 10 patients with stage II, III, or IV Kienböck's disease who were treated only with radial shortening and followed up for an average of 25 months. The three patients who became worse as determined by x-ray evaluation had lunate fossa inclinations of less than 12 degrees after surgery. The four patients who improved had lunate fossa inclinations greater than 12 degrees. Appropriate radial shortening with adjunct wedge osteotomy to increase lunate fossa inclination may prevent further lunate collapse.

Functional results of vascularized versus nonvascularized nerve grafting

Functional results of vascularized nerve grafts (VNG), end-to-end (E-E) repair, and nonvascularized nerve grafts (NNG) were compared using 75 rats. For all three groups, the sciatic function index (SFI) was measured for 12 weeks. For the vascularized nerve graft and nonvascularized nerve graft groups, it was measured every 4 weeks to week 36. The vascularized nerve graft and end-to-end repair groups showed significantly better recovery than the nonvascularized nerve graft group 4 weeks after surgery, and this pattern continued throughout the experiment. Results from the vascularized nerve graft and end-to-end repair groups did not differ significantly. Twelve weeks after surgery, morphologic and electrophysiologic assessments were used to compare the experimental and contralateral legs. The vascularized nerve graft group showed significantly better recovery than the nonvascularized nerve graft group on all measures except muscle weight and axon count, even though the grafts were completed in a normal bed.

The osteocutaneous fibula flap: an anatomic study

Recent studies related to the fibula flap have disagreed regarding the anatomy of the cutaneous branches of the peroneal artery. To clarify this issue, various dissections of 35 injected fresh cadaver legs were done. Identifiable skin branches were found in 23 of 25 dissections. Skin branches from the proximal third of the peroneal artery always travelled an intramuscular course. Skin branches from the distal two-thirds of the peroneal artery were usually affixed to the posterior crural septum. Legs with peroneal artery skin branches had from three to seven branches (average: 4.7); each branch contributed to the fibular periosteal blood supply. The most reliably found skin branch was located within 2 cm of the fibula midpoint. These findings reinforce the fact that a large skin island supplied by branches of the peroneal artery can be harvested with the fibula flap, and that the most reliable cutaneous vessels are found in the lower two-thirds of the leg, run posterior to the fibula in the posterior crural septum, and are always associated with muscular side branches.

Sensory and motor fiber differentiation with Karnovsky staining

We examined four acetylthiocholine methods based on Karnovsky's procedure--two fast-acting requiring 1 hour and two slow-acting requiring 24 hours. We compared these with our modification, which requires less than an hour and is simple to use. Rabbit sciatic nerves and spinal cords were used to compare methods. Our modification showed clearer differentiation than other fast-acting methods and staining identical to slow-acting methods. In blind examination of radial nerve specimens stained with our method, motor and sensory fascicles were correctly identified, showing sensitivity and specificity of 100%. In 12 clinical cases, our method produced staining in the proximal stump as long as 16 months after injury and in the distal stump as long as 5 days after injury. In 10 of 12 patients, this staining helped in aligning motor fascicles to motor fascicles and sensory fascicles to sensory fascicles.

Revascularization of a finger with a thenar mini-free flap

A devascularized index finger with a soft tissue defect on its palmar side was managed by using a small free flap raised at the level of the metacarpophalangeal joint of the thumb. The radial digital artery was included in the flap and used to revascularize the index finger, and a palmar vein was used to drain the flap. This resulted in minimal donor side morbidity.

Toe-to-thumb transfer: a new technique

Our technique combines the advantages of two proven techniques of the wraparound flap and vascularized joint transfer while offering a more normal thumb, both functionally and cosmetically. Its advantages are as follows: 1. A more normal-looking thumb with good length 2. Preservation of motion through joint transfer 3. Maintenance of growth potential through transfer of vascularized epiphyses 4. Minimal donor-site morbidity

Per Primam thumb replantation for all patients with traumatic amputations

Forty-two complete thumb replantations performed between 1980 and 1984 were reviewed. The mean follow-up time was 14 months. Replantation was attempted for all thumb amputations regardless of mechanism or severity of injury. Sixteen (38%) failed intraoperatively or postoperatively. Thumbs with narrow zones of injury showed a significantly higher survival rate than those with wide zones of injury. Eighty percent of those with poor arterial flow intraoperatively ultimately failed, despite pharmacologic treatment and multiple vein-graft anastomoses. Two thumbs with no vein repairs ultimately survived. Reexploration for loss of perfusion succeeded in 60% of cases. Total metacarpophalangeal and proximal interphalangeal active motion postoperatively averaged 68 degrees. Median static two-point discrimination returned to 11 mm. Avulsed thumbs survived in 46% of cases. Replantation should be attempted in all cases of thumb amputation, as success cannot be predicted by mechanism or severity of injury. Thumbs with poor intraoperative flow (20%) or no venous return (50%) can survive and should not be primarily amputated. Vein grafting is not mandatory if shortening allows anastomoses to be tension free. Prompt reexploration of acute vascular occlusions is worthwhile.

Vascularized single toe joint transfer to the hand

We report a retrospective review of our series of thirty-one single joints harvested from the toe in twenty-six patients and transferred to the metacarpophalangeal or proximal interphalangeal joint of the finger. Twenty-six transfers were done in traumatic cases and five in congenital. Follow-up averaged 22.6 months. Average range of motion was from 17.1 degrees to 44.3 degrees, with an arc of 27.2 degrees. The congenital group had an average motion ranging from 14.4 degrees to 27.2 degrees and an arc of 12.8 degrees. The traumatic group's motion was from 17.6 degrees to 47.6 degrees and an arc of 30.0 degrees. Complication rates were significant, with fifty percent of the patients experiencing one or more complications. Although vascularized joint transfer is a demanding procedure, it provides a reasonable alternative to arthrodesis and with further refinement in technique may become a reliable treatment option.

Free vascularized whole joint transfer in children

Reconstruction of the traumatized finger joint with epiphyseal destruction has long been problematic. Since free vascularized whole joint transfer was introduced as a treatment for joint and epiphyseal destruction, this procedure has been selected as an alternative treatment because it may provide a growing epiphysis. We have reviewed our series of 19 joint transfers. Mean age at operation was 6.2 years (range 3 to 12). Average active range of motion was 31 degrees/61 degrees for the group with posttraumatic reconstruction (n = 12) and 21 degrees/43 degrees for the group with reconstruction of a congenital deformity (n = 7), with an overall average of 27 degrees/54 degrees. Average range of motion following transfer of an metatarsophalangeal (MTP) or metacarpophalangeal (MCP) joint to an MCP joint position was 39 degrees/75 degrees (n = 4); proximal interphalangeal (PIP) to PIP transfer was 22 degrees/39 degrees (n = 13); and PIP to MCP transfer was 38 degrees/51 degrees (n = 2). The proximal phalanges in MCP joints transferred to the MCP position grew an average of 7.0 mm, and the middle phalanges of joints transferred to the PIP position grew 4.3 mm. Almost normal growth was observed in all transferred joints except two that showed premature epiphyseal closure. Indications for this procedure and techniques to improve range of motion are described.

The repair of nail deformities with the nonvascularized nail bed graft: indications and results

Twenty-four cases of nonvascularized nail bed grafting to correct nail deformities were reviewed. The highest success rate in improving the appearance of the deformed nail, 86%, was achieved when the split-thickness nail bed graft of sterile matrix was used to correct a nail deformity caused by a sterile matrix injury; the same procedure used to correct a nail deformity caused by a germinal matrix injury had a 0% success rate. Donor site morbidity occurred in 25% of split-thickness nail bed grafts and 100% of full-thickness nail bed grafts. The split-thickness nail bed graft of sterile matrix, if used in properly selected patients, will consistently improve the appearance of the deformed nail.

Improvement in motor function after brachial plexus surgery

Motor functional recovery of 52 patients with brachial plexus surgery followed up for more than 2 years was evaluated. Fifty-eight surgical procedures were done, including autologous nerve grafting (38 cases), neurolysis (14 cases), and neurotization (6 cases). Overall results, evaluated according to the 0 to 5 formula of the Medical Research Council, were as follows: good, 58%; fair, 15%; and poor, 27%. Good results were evident in 58% of patients with nerve grafts and in 64% of those with neurolysis. In patients with neurotization, no good recovery and only one fair recovery were seen. Patients with open injuries showed good recovery, whereas the group with closed injury showed good recovery in only 48%. Patients with closed injuries caused by traffic accidents showed a worse recovery than those caused by other means. Patients with closed injuries and nerve grafting done within 3 months of injury or neurolysis within 6 months showed better recovery.

Experimental replantation of canine forelimbs after 78.5 hours of anoxia

To assess the effect of ischemia on osteocyte survival and longitudinal growth in bone, one forelimb of eight puppies and seven dogs was amputated, perfused with iced Collins solution, maintained at 4 degrees C for 72 hours (78.5 hours total anoxia), and replanted. Five puppies were kept for 1 year to assess bone growth. Undergoing bone labeling on days 1, 8, and 15, the other animals were sacrificed at 22 days to assess osteocyte survival. Osteocytes survived replantation in all dogs and one puppy; most osteocytes died in two puppies. In five long-term puppies, central epiphyseal growth was disturbed, but the peripheral portions maintained nearly normal growth, with almost normal bone length being achieved at 1 year.