Effect of PEEK polymer on tunnel widening after hamstring ACL reconstruction

The purpose of this study was to evaluate the effect of the AperFix device (Cayenne Medical, Inc, Scottsdale, Arizona), composed of polyetheretherketone (PEEK) polymer, on tunnel widening after hamstring anterior cruciate ligament (ACL) reconstruction as compared with 2 other fixation devices: the TransFix (Arthrex, Inc, Naples, Florida) and the EndoButton (Smith & Nephew Endoscopy, Mansfield, Massachusetts). Sixty-seven patients with isolated total ACL ruptures who underwent arthroscopically assisted reconstruction using hamstring autografts at the authors' institution were included in the study. Patients were assigned into 1 of 3 groups in a nonrandomized fashion: AperFix (n=18), TransFix (n=29), and EndoButton (n=20). Mean follow-up was 30 months. Tunnel widening measurements were performed on anteroposterior and lateral digital plain radiographs taken in postoperative week 1 and at final follow-up. Laxity testing, Lysholm scoring, and arthrometric evaluation were performed.All 3 graft fixation devices resulted in significant tunnel widening in both tibial and femoral tunnels at final follow-up when compared with the immediate postoperative period. Tunnel widening between groups was not significantly different in terms of coronal and sagittal femoral tunnel diameters. Tibial tunnel diameter increase in the sagittal plane in the EndoButton group was significantly smaller than that in the TransFix and AperFix groups. No correlation was found between the amount of tunnel enlargement and clinical outcomes of ACL surgery. This study's findings suggest that tunnel enlargement after ACL reconstruction is influenced by the type of graft fixation on the tibial side irrespective of clinical outcome, and PEEK polymer does not have an effect on tunnel widening after hamstring ACL reconstruction.

Prefabrication of axial vascularized tissue engineering coral bone by an arteriovenous loop: a better model

The most important problem for the survival of thick 3-dimensional tissues is the lack of vascularization in the context of bone tissue engineering. In this study, a modified arteriovenous loop (AVL) was developed to prefabricate an axial vascularized tissue engineering coral bone in rabbit, with comparison of the arteriovenous bundle (AVB) model. An arteriovenous fistula between rabbit femoral artery and vein was anastomosed to form an AVL. It was placed in a circular side groove of the coral block. The complex was wrapped with an expanded-polytetrafluoroethylene membrane and implanted beneath inguinal skin. After 2, 4, 6 and 8 weeks, the degree of vascularization was evaluated by India ink perfusion, histological examination, vascular casts, and scanning electron microscopy images of vascular endangium. Newly formed fibrous tissues and vasculature extended over the surfaces and invaded the interspaces of entire coral block. The new blood vessels robustly sprouted from the AVL. Those invaginated cavities in the vascular endangium from scanning electron microscopy indicated vessel's sprouted pores. Above indexes in AVL model are all superior to that in AVB model, indicating that the modified AVL model could more effectively develop vascularization in larger tissue engineering bone.

A new technique in double-bundle anterior cruciate ligament reconstruction using implant-free femoral fixation

PURPOSE

The study is a prospective case-series analysis to demonstrate a new double bundle technique for anterior cruciate ligament (ACL) reconstruction with the use of hamstring tendons through a single tibial tunnel, a double femoral socket with implant-free femoral fixation and interference screw for tibial fixation.

MATERIALS AND METHODS

Twenty-one patients were treated with the same technique. Hamstring tendons were not removed from the tibial side, and using a single tibial and a double femoral tunnel of 8 and 6 mm, respectively, anatomic ACL reconstruction was performed. Graft passage was performed from the tibial side to the posterolateral femoral tunnel and was looped back to the anteromedial femoral tunnel to be fixed on the tibial tunnel with an interference screw and additional extracortical fixation. Follow-up of the study group was performed for a two-year period, documenting standard clinical and radiographic parameters.

RESULTS

Post-operative follow-up (mean 24 months) revealed radiological widening of tibial tunnel (mean 133.6%) in all patients and minor femoral tunnels widening (119.4% and 117.5%). Clinical evaluation showed no signs of instability, and knee evaluation using the IKDC score was performed.

CONCLUSION

The manuscript describes a novel technique in ACL reconstruction, and reports the radiographic results of tunnel widening and clinical scores. Implant-free femoral fixation led to minor tunnel widening similar to previously published data. Further studies need to be performed to compare the long-term results with different published techniques of cost-effective implant-free ACL reconstruction.

A comparison of parallel and diverging screw angles in the stability of locked plate constructs

We investigated the static and cyclical strength of parallel and angulated locking plate screws using rigid polyurethane foam (0.32 g/cm(3)) and bovine cancellous bone blocks. Custom-made stainless steel plates with two conically threaded screw holes with different angulations (parallel, 10° and 20° divergent) and 5 mm self-tapping locking screws underwent pull-out and cyclical pull and bending tests. The bovine cancellous blocks were only subjected to static pull-out testing. We also performed finite element analysis for the static pull-out test of the parallel and 20° configurations. In both the foam model and the bovine cancellous bone we found the significantly highest pull-out force for the parallel constructs. In the finite element analysis there was a 47% more damage in the 20° divergent constructs than in the parallel configuration. Under cyclical loading, the mean number of cycles to failure was significantly higher for the parallel group, followed by the 10° and 20° divergent configurations. In our laboratory setting we clearly showed the biomechanical disadvantage of a diverging locking screw angle under static and cyclical loading.

Diffuse idiopathic skeletal hyperostosis of the cervical spine: an underestimated cause of dysphagia and airway obstruction

BACKGROUND CONTEXT

Diffuse idiopathic skeletal hyperostosis (DISH) is a common but underdiagnosed condition relating to ossification of spinal ligaments that can cause compression of the esophagus and trachea. According to case reports, dysphagia or airway obstruction resulting from DISH is a rare occurrence.

PURPOSE

This study was intended to identify all published cases of dysphagia and/or airway obstruction resulting from DISH to increase the epidemiologic/clinical knowledge of these related conditions.

STUDY DESIGN

A systematic review of the literature was performed.

METHODS

The articles resulting from the systematic PubMed/EMBASE search of the literature were closely read, and predefined parameters were scored.

RESULTS

The search yielded a total of 118 articles (95 case reports and 23 case series) describing 204 patients with dysphagia and/or airway obstruction resulting from DISH. The number of cases demonstrated a steady increase from 1980 to 2009. This might be a real effect not ascribable to publication bias or expansion of the medical literature alone.

CONCLUSIONS

Diffuse idiopathic skeletal hyperostosis as a cause of dysphagia and/or airway obstruction may be an increasing and underappreciated phenomenon. Diffuse idiopathic skeletal hyperostosis should be included in the differential diagnosis of dysphagia and airway obstruction.

An unusual high-pressure injection injury involving the cervical spinal cord

High-pressure injection injuries occur infrequently but are usually work-related and involve the non-dominant hand. The neck is a very rare site for such an injury. We describe the management of a 36-year-old man with a high-pressure grease-gun injection injury to his neck causing a cervical spinal cord injury. He developed severe motor and sensory changes which were relieved by surgical removal of the grease through anterior and posterior approaches.

Multiple toe transfer and sensory free flap use after a traumatic amputation of multiple digits. Surgery done in a single setting: a case study

Crush avulsion injuries to the hand with concomitant traumatic amputation of multiple digits can be a devastating injury to the patient. These injuries have multiple issues occurring under emergency conditions. When feasible, replantation of the multiple digits is optimal, but in many cases, it is not possible. Because of the crushing force on the digits, they are not viable candidates for replantation. The usual course of treatment for these patients is a two stage procedure, usually involving a groin flap. Here, we present the case of a patient who had a left hand skin avulsion of the whole palm and P1 of index, long, ring and small fingers. The left index finger had a complete amputation at the P2 level, the long, ring and small fingers all had complete amputations at the P1 level. This injury was dealt with by a left foot second and third toe transplant, a sensory free flap from the left big toe and a fourth toe microvascular free transfer to the left hand. The remainder of the defect was managed with a 10 × 14 cm reversed radial forearm flap and a combination of full and split thickness skin grafts. The procedure was performed in a single operation, obviating the need for a second surgery. This procedure optimized the patient's outcome during a single setting, making it an ideal choice in an emergency setting.

Relation of tunnel enlargement and tunnel placement after single-bundle anterior cruciate ligament reconstruction

PURPOSE

To determine the relation between tunnel placement and tunnel enlargement after single-bundle anterior cruciate ligament (ACL) reconstruction.

METHODS

Seventy-two subjects (mean age, 30.1 years; 17.5 months' follow-up) who underwent single-bundle ACL reconstruction with hamstring autograft were studied. EndoButton fixation (Ethicon, Somerville, NJ) was used on the femoral side, whereas staples were used on the tibial side. A transtibial femoral tunnel position technique was used in 53 subjects, whereas positioning through the medial portal was used in the other 19 cases. Tunnel enlargement was determined by comparing the diameter of the tunnel on the radiograph obtained after 12 months and the radiograph obtained instantly after the operation. The centers of the femoral and tibial tunnels and the angles between the graft and tibial plateau were also measured on standard radiographs. Clinical outcomes including KT-1000 assessment (MEDmetric, San Diego, CA) and International Knee Documentation Committee (IKDC) score were also collected in all patients. The relations between tunnel enlargement/tunnel position and knee joint laxity and IKDC score were analyzed.

RESULTS

The mean KT-1000 side-to-side difference significantly decreased, from 6.07 ± 2.75 mm to 1.57 ± 2.14 mm, after ACL reconstruction; the IKDC subjective score increased from 52.8 to 87.5. On lateral radiographs, the tunnel enlargement rates were 41% on the femoral side and 35% on the tibial side; on plain anteroposterior radiographs, the tunnel enlargement rates were 39% on the femoral side and 32% on the tibial side. Subjects with a higher femoral tunnel had a greater enlargement rate (P < .001). Subjects with a more vertical graft also had a larger femoral enlargement (P < .05). More anterior placement of the femoral tunnel was associated with larger tibial tunnel enlargement on anteroposterior plain radiographs (P < .05). A more vertical graft was also associated with larger tibial tunnel enlargement. Subjects in whom the transtibial femoral position technique was used had more femoral tunnel enlargements (P < .01).

CONCLUSIONS

Drilling the femoral tunnel through the medial portal created a lower, more posterior, and less vertical tunnel than drilling through the tibial tunnel. Femoral and tibial tunnel enlargements were greater with more anterior, more proximal, and more vertical femoral tunnels. Whereas no clinical differences were seen in the 2 groups, drilling the femoral tunnel from the medial portal will result in smaller postoperative tunnel enlargements.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Fassier-Duval femoral rodding in children with osteogenesis imperfecta receiving bisphosphonates: functional outcomes at one year

PURPOSE

To examine the functional outcomes of children with osteogenesis imperfecta (OI) following initial Fassier-Duval (FD) rodding to the femur at 1 year, and to determine which factors are associated with change in gross motor function, ambulation, and functional performance.

METHODS

Approval from our Institutional Review Board was obtained. A retrospective chart review identified 60 children (28 males, 32 females) with OI who underwent initial FD femoral rodding (101 rods) and who were receiving bisphosphonates. The mean age of the children was 3 years, 11 months at the initial femoral FD rodding. Two had type I OI, 30 type III, 27 type IV, and one type VI. The maximum length of follow-up was 4 years. Telescoping FD rods were used for the femurs, with surgeries performed one leg at a time, with a 1-week interval. The active range of motion (AROM) of the hips and knees in flexion was measured 4-5 weeks post-initial rodding. Outcomes on the Gillette Functional Assessment Questionnaire (FAQ) Ambulation Scale, the Gross Motor Function Measure (GMFM), and the Pediatric Evaluation of Disability Inventory (PEDI) were compared pre-operatively and at 1 year post-surgery using t-tests and multivariate linear regression.

RESULTS

Pre-operatively, the mean FAQ score was 2.0, and this increased to 5.8 at 1 year post-surgery. Statistically significant improvements (P ≤ 0.05) were found on the FAQ, crawling, standing, walking and running, and total domains of the GMFM, and PEDI mobility and self-care from baseline to 1 year. The results from the multivariate linear regression indicate that older age (P = 0.0045) and higher weight (P = 0.0164) are significantly associated with lower scores in the self-care domain of the PEDI, and that OI type III compared to type IV is significantly associated (P = 0.0457) with greater improvement on the crawling domain of the GMFM. Higher weight was also associated (P = 0.0289) with lower scores in the standing domain of the GMFM, as well as with the total GMFM score (P = 0.0398).

CONCLUSIONS

Our findings indicate that initial FD femoral rodding resulted in benefits in ambulation, gross motor function, self-care, and mobility for children with OI beyond physiological expectations due to developmental growth. FD rodding is a procedure which can improve the overall mobility in children with OI with significant femoral deformities.

Serial dilation reduces graft slippage compared to extraction drilling in anterior cruciate ligament reconstruction: a randomized controlled trial using radiostereometric analysis

PURPOSE

This study tested the hypothesis that serial dilation of the tibial tunnel could provide a stronger anchorage of the graft-fixation-device complex compared to traditional extraction drilling.

METHODS

Forty patients (22 men and 18 women) undergoing ACL reconstruction were randomized to either extraction drilling (group ED) or compaction by serial dilation (group SD) of the tibial tunnel. Tantalum beads were placed in the tibia, femur, and in the hamstring graft. Radiostereometric analysis (RSA) was performed postoperatively and again after 6, 12, and 24 weeks. Migration of graft in the bone tunnels as well as knee laxity was assessed using RSA and a TELOS stress device.

RESULTS

Six patients (three men and three women) were excluded during follow-up, which resulted in 17 patients in group ED [median age 30 years (range 20-50)] and 17 patients in group SD [median age 32 years (range 20-49)]. The mean migration of the graft in the tibial bone canal after 3 months was 1.3 (SD 0.6) mm in group ED and 0.8 (SD 0.5) mm in group SD (P = 0.02). The overall knee laxity after 3 months was 13.0 (SD 4.0) mm in group ED and 10.9 (SD 3.1) mm in group SD.

CONCLUSION

This study found less slippage of the hamstring graft in the tibial bone canal in the serial dilated group compared to the extraction drilling group. The clinical relevance of the difference is unknown. No difference in stress radiographic knee laxity was found between the two groups.

Early or delayed limb lengthening after acute shortening in the treatment of traumatic below-knee amputations and Gustilo and Anderson type IIIC open tibial fractures: The results of a case series

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5). All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly.

Mind your hand during the energy crunch: Functional Outcome of Circular Saw Hand Injuries

Background

Although injuries due to circular saws are very common all over the world, there is surprisingly little information available about their functional outcomes. As the socioeconomic impact of these injuries is immense and determined by the casualties' disability and impairment, it is the objective of this study to present data on the functional outcome, disability, and impairment of hand injuries due to electric circular saws.

Methods

Patients treated from 1999 through 2007 for circular saw-related hand injuries were contacted and asked for clinical follow-up assessment. The clinical follow-up protocol consisted of a physical examination and an assessment of static muscle power (grip and pinch strength). For assessment of the subjective experience of the patients regarding their injury-related disability and impairment, the DASH follow-up questionnaire was used. The occupational impact of these injuries was measured by number of lost working days. Finally, safety-related behaviour of the patients was investigated.

Results

114 Patients were followed-up on average 52 months after the injury. Average in-house treatment was 8.8 days. Average time lost from work was 14.8 weeks. A significant reduction of static muscle testing parameters compared with the uninjured hand was revealed for grip strength, tip pinch, key pinch, and palmar pinch. Average DASH score was 17.4 (DASH work 15.8, DASH sports/music 17.7). Most patients had more than ten years experience in using these power tools.

Conclusion

The everyday occurrence of circular saw-related hand injuries followed by relatively short periods of in-house treatment might distort the real dimension of the patients' remaining disability and impairment. While the trauma surgeon's view is generally confined to the patients' clinical course, the outcome parameters in this follow-up investigation, with loss of working time as the key factor, confirm that the whole socioeconomic burden is much greater than the direct cost of treatment.

[High pressure injection injuries of the hand. Rare but often underestimated]

INTRODUCTION

Injection injuries of the hand are often underestimated because the full extent of the injury often only emerges after a delay. Flap coverage is often needed to avoid amputation.

CASE REPORT

In the case presented an epoxy resin injection trauma to the left index finger occurred. A critical blood circulation resulted and after demarcation of the injury a radical débridement was carried out. A heterodigital island flap was used to reconstruct the dorsum of the finger and 3 years after the trauma the patient has no impairments in daily activities.

DISCUSSION

The extent of the injury and the carcinogenic properties of the injected material are crucial for adequate treatment of injection injuries. Patients should be referred to specialized hand centers at an early stage.

Serial dilation versus extraction drilling in anterior cruciate ligament reconstruction: a biomechanical study

The hamstring tendon graft has become increasingly popular in anterior cruciate ligament reconstruction because of low donor-site morbidity. However, the tibial fixation is considered difficult, mainly because of low tibial mineral bone density. Therefore, we tested whether preparation of the tibial tunnel with compaction by serial dilation provided a stronger anchorage of the graft-fixation-device complex than does traditional extraction drilling of the tibial tunnel. In 20 bovine tibiae, the bone tunnels were created with either extraction drilling (group 1) or compaction by serial dilation (group 2). Twenty bovine digital extensor tendons were fixated in the bone tunnel with an Intrafix tibial fastener. The graft-fixation-device complexes were mounted in a hydraulic test machine. The fixation strength was evaluated after cyclic loading. The difference between the serial dilation group and the extraction drilling group ranged from a mean slippage of 0 mm at 70-220 N, to a mean slippage of 0.1 mm at 70-520 N. We found no significant difference in slippage of the graft-fixation-device complex after 1,600 cycles. This study failed to show a significant difference between compaction by serial dilation and extraction drilling of the tibia bone tunnel in anterior cruciate ligament reconstruction.

Effects of local tramadol administration on peripheral glutamate-induced nociceptive behaviour in mice

PURPOSE

The use of peripheral tramadol to block pain has been advocated. However, since its actions in the periphery have not been elucidated fully, we tested the hypothesis that peripheral tramadol blocks peripheral glutamate-induced nociceptive behaviour in mice.

METHODS

First, we compared the duration of paw licking after intraplantar (ipl.) glutamate administration, with and without tramadol, using a randomized blinded controlled design. Next, we established the half maximal effective concentrations (EC(50s)) for local tramadol and reference compound lidocaine in the hot water tail-flick latency test and the glutamate-induced paw allodynia assay.

RESULTS

Tramadol reduced glutamate-induced paw licking from 33 +/- 12 sec to 4 +/- 4 sec (mean +/- SD; t test, P < 0.05; n = 6 per group). The tramadol and lidocaine EC(50) nerve conduction blocks in the tail did not differ significantly (84 +/- 24 mM vs 69 +/- 5 mM, respectively). Although tramadol reduced glutamate-induced allodynia (EC(50), 46 +/- 13 mM), lidocaine was more potent (EC(50), 13 +/- 5 mM; Dixon's up-and-down method; P < 0.05). Tramadol was 2.5 times as effective at blocking nerve conduction in the tail compared with allodynia in the paw.

CONCLUSIONS

Local tramadol administration blocked nociceptive behaviour in mice induced by peripheral glutamate. Compared with lidocaine, the relative potency of tramadol was lower for blocking glutamate-induced allodynia than for sensory nerve conduction blockade, suggesting the activation of a pronociceptive receptor system in the periphery.

Accidental circular saw hand injuries: trauma mechanisms, injury patterns, and accident insurance

INTRODUCTION

Hand injuries due to circular saws are a common reason for patients seeking medical care in emergency departments. With respect to cases of insurance fraud, these injuries are of medico-legal interest. It is the aim of this study to investigate the critical circumstances of the incidents, the accident mechanism, and the specific injury patterns of circular saw related hand injuries with regard to accident insurance coverage.

PATIENTS AND METHODS

Circular saw related hand injuries for the years 1999 through 2007 were followed-up and assessed in detail. Type, severity and pattern of the injury were assessed. An accident analysis investigated characteristic of the activities, of the saws, of the stock/cutting material, operational activities of the operators prior to/at the time of the incident, and detailed information on the insurance status.

RESULTS

The follow-up study encompassed 114 patients. A majority of these were covered by private or statutory accident insurances. Compensation payments were made in all cases. All lesions involved one hand, mainly the left non-dominant hand. Thumb and index were at highest risk for injury. One-finger injuries occurred mainly at the middle or distal phalanx. With increasing number of affected fingers, the level of the injury moved closer to the proximal phalanx. A majority of injuries occurred during do-it-yourself activities. Among blade contact injuries, the so-called kickback-mechanism was at highest risk.

CONCLUSION

Positive circumstantial indications of a self-inflicted injury, which are often cited in the literature are less conclusive for the medico-legal decision finding. The detailed anatomic description of any lesions and the alleged accident mechanism as initially described by the patients in the emergency setting is the basis for any later accident reconstruction.

Humane killers, human injury: functional outcome of vole captive bolt injuries

BACKGROUND

High-pressure blast injuries to the hand due to vole captive bolt devices are serious injuries that are to a great extent unknown to emergency care operators and trauma surgeons. There is no study on the functional outcome of these patients.

METHODS

We assessed the functional outcome of patients with injuries inflicted by vole captive bolt devices. Therefore, a protocol consisting of a physical examination and an assessment of static muscle power (grip and pinch strength) was performed. To capture the subjective experience of patients regarding their injury related disability and impairment, the DASH follow-up questionnaire was used. Based on clinical/radiologic findings and outcome, a classification of this unique subgroup of blast injuries was developed.

RESULTS

The functional outcome of 34 patients suffering hand injuries due to captive bolt devices between 2004 and 2007 was assessed. A significant reduction of static muscle testing parameters compared with the uninjured hand was revealed. Fourteen patients lost a digit. Average time lost from work was 5.4 weeks.

CONCLUSION

Vole captive bolt device-related hand injuries are followed by deterioration of hand function. The present observations alarmed national authorities. The manufacturers were required to take engineering and teaching measures to rule out handling errors that were identified as leading cause of injury.

Anesthesia and postoperative analgesia after intra-articular injection of warmed versus room-temperature levobupivacaine: a double-blind randomized trial

PURPOSE

This prospective, randomized, blinded study was designed to compare the effects of warmed versus room-temperature levobupivacaine in patients undergoing knee arthroscopy and partial meniscectomy.

METHODS

Patients were randomly allocated into 2 groups of 16 patients each. In all patients the 2 portal sites were infiltrated with 10 mL of room-temperature mepivacaine (20 mg/mL). In the first group, patients underwent intra-articular injection of 20 mL of levobupivacaine (5 mg/mL) and 0.005-mg/mL epinephrine (1:200,000) at a temperature of 40 degrees C +/- 0.2 degrees C, whereas in the second group the levobupivacaine and epinephrine were at room temperature (25 degrees C +/- 0.5 degrees C). Pain was graded and recorded intraoperatively and postoperatively by use of a visual analog scale (VAS). Analgesia was supplemented if the VAS score was 4 cm or greater with morphine intraoperatively or ketorolac postoperatively.

RESULTS

There were no significant differences between groups in intraoperative and postoperative VAS values. There was no need for morphine as a rescue dose in any patient during surgery. Eight patients treated with warmed levobupivacaine and seven patients treated with room-temperature levobupivacaine requested a single rescue dose of ketorolac (30 mg) postoperatively.

CONCLUSIONS

No compelling evidence exists to suggest that intra-articular injection of warmed levobupivacaine is more effective than room-temperature levobupivacaine for intraoperative anesthesia and postoperative analgesia in patients undergoing partial meniscectomy during knee arthroscopy.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

What to do with non-replanted hands?

We describe a method for the preparation of amputated limbs to obtain a specimen for anatomical study of the arteries and the skeleton. The procedure is particularly applicable to hands, and prevents the destruction of a perfect hand that cannot be replanted.

Groin flap immobilization by axillary brachial plexus block anesthesia

Pedicled groin flaps are still widely used as soft tissue coverage in hand surgery. Various methods have been described for immobilization of flaps, such as Ace wraps, plaster, and external fixators. The hands of 5 females and 12 males, totaling 17 patients, with severe injury were reconstructed with groin flaps between 2001 and 2005. Patients were operated on under a combination of axillary block and general anesthesia. Motor block effect of axillary anesthesia was used for immobilization of the upper extremities at groin flap coverage. A combination of axillary brachial plexus block plus general anesthesia had advantages in the prevention of pedicle tension or torsion during the initial recovery period. Reduction of general anesthesia time and improvement of postoperative pain were also observed. Axillary brachial plexus block and general anesthesia are a preferred combination for patients undergoing groin flap operations.

Functional transposition of the latissimus dorsi muscle for biceps reconstruction after upper arm replantation

Major upper arm amputations are often accompanied by different levels of soft-tissue divisions involving crushing, traction, and avulsion injuries to various structures. In these cases the goal is not only the re-establishment of circulation, but also functional outcome. Some patients require further reconstruction for functional restoration of elbow flexion and additional soft tissue coverage. Five patients underwent functional latissimus dorsi transfer for restoration of elbow flexion after successful upper arm replantation at our institution. The transfer was unipolar in four patients and bipolar in one. The patients' ages ranged from seven to 55 years. The time period between replantation and transfer ranged from two weeks to 12 months. All flaps healed well with minimal donor site morbidity. At mean 43-month follow-up (range: 22-65 months), functional results were good with M4 in three patients and M3 in two patients for elbow flexion. The pedicled latissimus dorsi muscle flap is a valuable tool to restore elbow flexion and provide coverage of soft tissue defects after major upper arm replantations.

Long-term review of five leg replantations: emergency strategy and examples of lengthening of the leg on nerve regeneration

The success rate for leg replantation has improved with the development of shortening-lengthening protocols. We checked whether this success was maintained long term in five cases of emergency reimplantation. The significant initial shortening of 93 mm, on average, enabled direct internal osteosynthesis, secondary lengthening was initiated swiftly, in the proximal metaphyseal area, and average lengthening was 85 mm. Consolidation was achieved in all cases within normal time periods, with an average inequality in residual length of 8mm. The speed of nerve regeneration was on average 1.926 mm/day, twice faster than usual after simple nerve suturing. At average follow-up of more than 11 years, all patients were walking. We conclude that nerve lengthening stimulates nerve regeneration, and that the results of this protocol, involving extensive initial debridement compensated by secondary lengthening, have enabled the limitations on unilateral leg replantation to be reduced.

[Long-term follow-up after leg replantation]

Leg replantation is generally considered to yield good results, particularly since the widespread use of progressive lengthening procedures. This optimism must be weighted against the very long and difficult operative program, the social and occupational implications, and the functional outcome of the replanted limb. We report a case of below knee leg replantation in a young patient whose operative program lasted 29 months. Occupational activities were interrupted for three years. The clinical result was satisfactory but with 14 degrees residual valgus suggesting a potential risk of osteoarthritis and difficult therapeutic decisions. The alternatives to replantation are controversial. Leg transplantation is not a valid option in our opinion. Amputation with orthesis should be considered more often because complications are rare and recovery much shorter. Indications for leg replantation should be considered with prudence.