Long-Term Outcome of Phrenic Nerve Transfer in Brachial Plexus Avulsion Injuries

INTRODUCTION

In brachial plexus injuries, useful recovery of arm function has been documented in most patients after phrenic nerve transfer after variable follow-up durations, but there is not much information about long-term functional outcomes. In addition, there is still some concern that respiratory complications might become manifest with aging. The aim of this study was to report the outcome of phrenic nerve transfer after a minimum follow-up of 5 years.

PATIENTS AND METHODS

Twenty-six patients were reviewed and evaluated clinically. Age at surgery averaged 25.2 years and follow-up averaged 9.15 years.

RESULTS

Shoulder abduction and external rotation achieved by transfer of phrenic to axillary nerve (or posterior division of upper trunk), combined with spinal accessory to suprascapular nerve transfer, were better than that achieved by transfer of phrenic to suprascapular nerve, combined with grafting the posterior division of upper trunk from C5, 52.3 and 45.5 degrees versus 47.5 and 39.4 degrees, respectively. There was no difference in abduction when the phrenic nerve was transferred directly to the posterior division of upper trunk or to the axillary nerve using nerve graft. Elbow flexion (≥M3 MRC) was achieved in 5 (83.3%) of 6 cases. Elbow extension M4 MRC or greater was achieved in 4 (66.6%) of 6 cases. All patients, including those who exceeded the age of 45 years and those who had concomitant intercostal nerve transfer, continued to have no respiratory symptoms.

CONCLUSIONS

The long-term follow-up confirms the safety and effectiveness and of phrenic nerve transfer for functional restoration of shoulder and elbow functions in brachial plexus avulsion injuries.

Clinical and microbiological efficacy of MDT in the treatment of diabetic foot ulcers

OBJECTIVE

To assess the clinical and microbiological efficacy of maggot debridement therapy (MDT) in the management of diabetic foot ulcers unresponsive to conventional treatment and surgical intervention.

METHOD

Consecutive diabetic patients with foot wounds presenting at the vascular surgery unit and the diabetic foot unit of Alexandria Main University Hospital were selected for MDT. Lucilia sericata medicinal maggots were applied to the ulcers for three days per week. Changes in the percentage of necrotic tissue and ulcer surface area were recorded each week over the 12-week follow-up period. Semiquantitative swab technique was used to determine the bacterial load before and after MDT.

RESULTS

The sample comprised 10 patients with 13 diabetic foot ulcers. The mean baseline ulcer surface area was 23.5cm2 (range 1.3-63.1), and the mean percentage of necrotic tissue was 74.9% (range 29.9-100). Complete debridement was achieved in all ulcers in a mean of 1.9 weeks (range 1-4). Five ulcers (38.5%) were completely debrided with one three-day MDT cycle. The mean reduction in ulcer size was significant at 90.2%, and this occurred in a mean of 8.1 weeks (range 2-12). The mean weekly reduction in ulcer size was 16.1% (range 8.3-50). Full wound healing occurred in 11 ulcers (84.6%) within a mean of 7.3 weeks (range 2-10). The bacterial load of all ulcers reduced sharply after the first MDT cycle to below the 10(5) threshold, which facilitates healing.

CONCLUSION

The results highlight the potential benefits of MDT in diabetic wound care in developing countries. MDT was proved to be a rapid, simple and efficient method of treating these ulcers.

Tendon transfer around the shoulder in obstetric brachial plexus paralysis: clinical and computed tomographic study

One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders. Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years. On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation. The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.

Reconstruction of lower limb bone defects after sarcoma resection in children and adolescents using free vascularized fibular transfer

This study included 11 patients with lower limb tumors who had wide local resection and reconstruction by vascularized fibula osteoseptocutaneous flap and their surgery performed at least 24 months before the end of the study. The average age at operation was 14.4 years. All tumors, except one, were high-grade sarcomas (stage IIA, IIB, and Ewing's sarcoma). The tumor volume averaged 200.6 cm3 (range 41.5-400). The resulting defect after tumor resection averaged 14.8 cm (range 9-20). The fibula was inserted as a single strut in eight patients and as a double-barrel construct in three patients. Fixation was augmented by interlocking nail in four cases, bridge plate in five cases and external fixator in two cases. All flaps survived. All grafts united in an average period of 3.9 months (range 3-8) after transfer. Full weightbearing was possible after an average period of 6 months (range 6-10). Significant hypertrophy (>/=30% of the original fibular diameter) occurred in all patients after an average period of 10 months from the index operation. In the latest follow-up radiographs (mean 38 months), the degree of hypertrophy averaged 96.6% (range 30-200%). Graft fracture occurred in one patient after plate removal and healed conservatively. Shortening averaged 1 cm (range 0-3). The Musculoskeletal Tumor Society rating score averaged 21 points at the end of the first postoperative year and 23 at the end of the study.

Surgical treatment of brachial plexus traction injuries in children, excluding obstetric palsy

Traumatic brachial plexus injuries in children, excluding birth palsy, are seldom reported. In this study, we report on 11 cases operated upon between 1995-1998, and followed for at least 30 months. All patients were males with an average age of 11 years (range, 3-16 years). The denervation time averaged 3.8 months (range, 1-8 months). Eight patients had two or more root avulsions; two had additional severe infraclavicular injuries. In total, 6 grafting and 25 extraplexal neurotization procedures were used. Donor nerves included the intercostal nerves, phrenic nerve, spinal accessory nerve, and contralateral C7 root. Elbow flexion was restored in all but 2 cases. Shoulder abduction varied from 30-90 degrees, according to the method of reconstruction. Triceps recovered in 2 cases and finger and wrist extensors in 1 case. Wrist and finger flexion was obtained in 1 case. Sensory recovery in the palm reached S2/S2+. Harvesting the phrenic nerve and the contralateral C7 root resulted in no residual morbidity. Compared to adults, children have a higher incidence of root avulsion, no deafferentiation pain, a higher incidence of associated skeletal injuries, and the same recovery rate of elbow and shoulder functions following plexus reconstruction, but recovery is faster. Given the frequency of root avulsions, neurotization is often required.

Hypertrophy after free vascularized fibular transfer to the lower limb

This study included 25 patients with lower limb tumors who had reconstruction by vascularized fibula osteoseptocutaneous flap performed at least 24 months before the end of the study. Hypertrophy of the transplanted fibula was estimated on serial radiographs by a modification of the formula of De Boer and Wood (J Bone Joint Surg [Br] 71:374-378, 1989). A significant graft was observed in 90% of the patients at an average follow-up of 27 months (range, 30-200%). The time to graft union (start of partial weight-bearing) positively correlated with the time to significant graft hypertrophy (r = 0.9, P < 0.01). The final amount of graft hypertrophy was affected by the age of the patient (P < 0.01) and the length of follow-up (P < 0.05). Graft hypertrophy progressed at an average rate of 3.3% per month (range, 2.3-4.9%) until the end of the 30th month; thereafter, little or no increase in graft hypertrophy was observed. The rate of graft hypertrophy showed two significant peaks at 6-12 months (P < 0.001) and at 18-24 months (P < 0.05). Patients younger than age 20 years showed faster hypertrophy, with a peak at the 12th month. Hypertrophy progressed faster in patients who received chemotherapy until the 12th month, and then declined sharply compared to those who did not receive chemotherapy.

Microsurgical reconstruction of lower limb bone defects following tumor resection using vascularized fibula osteoseptocutaneous flap

This study included 25 patients with lower limb tumors who had wide local resection and reconstruction by vascularized fibula osteoseptocutaneous flap, and who had their surgery performed at least 24 months before the end of the study. The average age at operation was 23.5 years. Twenty-three tumors were malignant;16 were staged as high-grade sarcomas (stage IIA, stage IIB, and Ewing's sarcoma). Tumor volume averaged 293.2 cc (range, 41.4-860). The resulting defect after tumor resection averaged 16 cm (range, 9-20 cm). The fibula was inserted as a single strut in 21 patients, and as a double-barrel construct in 4 patients. Fixation was augmented by interlocking nail in 11 cases, bridge plate in 9 cases, and external fixator in 5 cases. Twenty-four (96%) flaps survived. All grafts united in an average period of 4.5 months (range, 3-8 months) after transfer. Two secondary procedures were necessary to achieve graft union. Full weight bearing was possible after an average period of 7.5 months (range, 5-14 months). Significant hypertrophy (> or =30% of original fibular diameter) occurred in 85% of patients after an average period of 10 months from the index operation. In the latest follow-up radiographs (mean, 32 months), the degree of hypertrophy averaged 90% (range, 30-200%). Graft fracture occurred in three patients, and all healed conservatively. The Musculoskeletal Tumor Society rating score (MTSRS) averaged 21.2 points at the end of the first postoperative year, and 23.6 at the end of the study.

Shoulder fusion and free-functioning gracilis transplantation in patients with elbow and shoulder paralysis caused by poliomyelitis

Six children between 7-16 years of age presented with flail shoulder and elbow caused by poliomyelitis. Shoulder fusion was followed by free-functioning gracilis transplantation to replace the atrophied biceps muscle. The transplanted muscle was reinnervated by either the spinal accessory or phrenic nerve. Follow-up averaged 44 months (range, 56-23 months). All cases developed at least grade 3 power of elbow flexion and were able to place their hands to their mouths. Five out of 6 cases were able to flex their elbow against resistance. One case required tension readjustment, and elbow flexion contracture of 45 degrees developed in another case. On average, the transplanted gracilis started to contract 3 months after transplantation, and muscle power reached grade 2 at 5-6 months and grade 3 at 9-12 months. Muscles supplied by the spinal accessory nerve were earlier to contract and ultimately attained more power than those supplied by the phrenic nerve, probably because of easier rehabilitation. Shoulder fusion and free-functioning gracilis transplantation for biceps replacement provide a solution for restoration of function in children with flail shoulder and elbow, as caused by poliomyelitis. The procedure can be useful in other neuromuscular conditions, such as late-presenting Erb's palsy, especially when no other muscles are available for local transfer.

Three-phase double-arc plasma for spectrochemical analysis of environmental samples

A new instrument, which uses a three-phase current to support a double-arc argon plasma torch for evaporation, atomization and excitation of solid or powder samples, is described. The sampling arc is ignited between the first and second electrode while the excitation arc is ignited between the second and third electrode. Aerosol generated from the sample (first electrode) is swept by argon gas, through a hole in the second electrode (carbon tubing electrode), into the excitation plasma. A tangential stream of argon gas is introduced through an inlet orifice as a coolant gas for the second electrode. This gas stream forces the excitation arc discharge to rotate reproducibly around the electrode surface. Discharge rotation increases the stability of the excitation plasma. Spectroscopic measurements are made directly in the current-carrying region of the excitation arc. An evaluation of each parameter influencing the device performance was performed. Analytical calibration curves were obtained for Fe, Al, K, and Pb. Finally, the present technique was applied for the analysis of environmental samples. The present method appears to have significant, low cost analytical utility for environmental measurements.

Evaluation of the effectiveness of routine measles vaccination: case-control study

A retrospective case-control study was conducted in two primary schools located in eastern region of Cairo to evaluate the protective value of routine measles vaccination. A total of 230 children who had a previous measles illness were identified over 3 months period. Each case was matched to two controls based on age and sex. Vaccination status of the study children was ascertained through reviewing vaccination certificates The overall measles vaccine effectiveness was estimated at 53% (95% CI 71%-26%) There was an association between age of measles vaccination and vaccine effectiveness (VE) Primary vaccination failure due to young age of measles vaccination is the likely explanation of the low measles vaccine effectiveness. Adoption of two-dose measles vaccination policy with the second dose being given at older age needs to be considered to correct the problem of vaccine failure.

Evaluation of the effectiveness of dipstick haematuria and proteinuria in screening Schistosoma haematobium infection among school children in upper Egypt

This study aimed at evaluation of validity and reliability of dipstick haematuria and proteinuria in screening school children for Schistosoma haematobium infection. It included a random sample of 400 school children aged 6-15 years in rural area of Fayoum Governorate, upper Egypt. Urine samples of the studied children were tested parasitologically by urine filtration technique as a reference test and semiquantitatively for haematuria and proteinuria using urine reagent strips as screening tests. Results of the study revealed that haematuria was a better indicator for Schistosoma haematobium infection than proteinuria, as it was more sensitive (85.5% 73.4%, respectively), specific (94.4% 82.9%, respectively) and reliable (kappa=92% 80%, respectively). Moreover, it had stronger relationship with intensity of infection (r=0.88 & 0.67, respectively). A combination of different grades of haematuria and proteinuria did not significantly increase either sensitivity or specificity. Dipstick haematuria could be a valuable technique in screening rural Egyptian school children who are at risk of urinary schistosmiasis.

Studies on anopheline larvae in El Faiyum Governorate, Egypt

In Egypt, malaria is still reported as sporadic cases or small outbreaks particularly in El Faiyum Governorate. This paper aimed to identify and to study the breeding and seasonal activities of anopheline larvae. Spot light surveys were carried out in five different ecological areas (Karoun Lake, El Fedemean, El Siliyien, Kom-Osheim and Sinouris) from September 1991 to August 1992. Three species of Anopheles larvae were encountered: A. (Cellia) pharoensis (43%), A. (Cellia) sergenti (29.8%) and A. (Cellia) multicolor (27.2%). Several type of breeding places were encountered for the three species. A. pharoensis preferred clear, shallow, stagnant water with thick growth of vegetations an shae especially in rice fields. A. sergenti preferred clean, shallow to deep stagnant or slow-moving water with vegetations especially in small water collections in grassy areas and under palm trees. A. multicolor preferred shallow, stagnant water, sometimes partially exposed to sunlight especially in seepage water. The breeding waters for the three species were alkaline. Seasonal study of the anopheline larvae were conducted in three villages: Abheit El Hagar, El Zawia El Khadra and Tersa, in Sinouris Center during the year 1993. A. pharoensis larvae were abundant in the three villages in June, July, August and September with a peak in June. No breeding was noticed in January and February. A. sergenti larvae were abundant from September to November in the three villages, the lowest density was recorded in January and July in Abheit, in April in El Zawia and in June in Tersa. No breeding in February in the three villages was noticed and also in March in Abheit and Tersa. A multicolor larvae were recorded in Abheit and Tersa. In Abheit, the highest density was recorded in November with no breeding in January, February, March and June while in Tersa, the highest density was recorded in October and November with no breeding in January, February, March, April, July and December. The whole results were discussed.

Human scabies acquired from a pet puppy

Scabies is a very old contagious skin disease caused by itch mite, Sarcoptes scabiei which burrows into the stratum corneum. Nowadays, human scabies is one of the health problems among the school children. This paper dealt with a case of scabies in a preschool aged child who acquired the infestation from his pet puppy.

Natural Leishmania infections in two stray dogs and two Gerbillus pyramidum in Dakahlia Governorate, Egypt

In Egypt, zoonotic cutaneaus leishmaniasis (ZCL) and infantile visceral leishmaniasis (I.VL.) have been documented. Recently, in Dakahlia Governorate, three cases of indigenously acquired leishmaniasis (two VL. and one ZCL) have been reported. This paper aimed to search for the animal reservoir (s) of these two types of zoonotic leishmaniasis. Commensal and wild rodents as well as stray dogs were collected from concerned areas. Their role as animal reservoirs were investigated parasitologically (dogs and rodents) and serologically (rodents). Seropositivities as measured by the indirect haemagglutination tests were detected in six Rattus norvegicus (up to 1/256), two Acomys c. cahirinus (up to 1/128) and four Gerbillus pyramidum (up to 1/1024). However, Leishmania parasites were demonstrated as amastigotes (smear) and promastigotes (culture) in only two G. pyramidum. On the other hand, amastigotes of Leishmania parasites were demonstrated in splenic smears of two stray dogs, one from Bilkas Center and one from Dikarnis Center. Cultures of the splenic materials of dogs were not successful. The results indicated high probability for the presence of at least one focus of cutaneous leishmaniasis and one focus of visceral leishmaniasis. It is concluded that visceral leishmaniasis must be in mind when dealing with fever of obscure origin with hypersplenism or other suggestive manifestations.

Oral contraceptive and twinning: case-control study

A retrospective case-control study was conducted to investigate the risk of twinning following oral contraceptive (OC) use. A total of 157 women with twin deliveries were included from two major hospitals located in Cairo. Two controls selected from women with singletone deliveries were matched to each case of twin delivery on basis of maternal age and parity. Information on (OC) use prior to last pregnancy and date of last menstrual period was provided by interviewing the study women. Potential biases in the study design were discussed. The overall (OC) use prior to the last pregnancy was significantly higher in twin group in comparison with the controls (P < 0.05). The study provides an evidence of increased risk of twinning among conceptions occurring within less than 3 months from cessation of (OC) use (OR = 2.3, 95% confidence limits: 1.2 - 4.4).

Aortoiliac angioplasty: is there a need for other types of percutaneous intervention?

In a retrospective study, the authors compared results in 81 patients who underwent 117 percutaneous transluminal angioplasty (PTA) procedures in the iliac arteries and 21 patients who underwent iliac artery atherectomy. Both groups were similar with respect to symptoms and risk factors. The overall technical success rates were 97.4% for PTA and 100% for atherectomy. The initial clinical success was 92.8% for PTA and 100% for atherectomy. Complications requiring surgery occurred in four of 117 (3.4%) PTA and one of 21 (4.8%) atherectomy procedures. The 2-year patency rate for PTA was similar to that achieved with atherectomy in a smaller patient population. These results indicate that atherectomy does not offer any definite advantage over conventional PTA for the routine management of iliac lesions and make it difficult to justify the additional expense and complexity of this technique.

Grading and outcome prediction of cases of aneurysmal subarachnoid haemorrhage by bedside xenon cerebral blood flowmetry

Ninety-six patients with aneurysmal subarachnoid haemorrhage underwent serial measurement of regional cerebral blood flow throughout the period of their treatment over the period of 5 years (1983 to 1988). A portable bedside xenon cerebral blood flow machine was used in this study and the initial slope index (ISI) values showed a clear relationship between reduction of cerebral blood flow and deteriorating clinical grade. Furthermore, serial measurements showed a statistically significant relationship between drop of cerebral blood flow, at anytime during the course of the disease, and fatal or less than satisfactory outcome.

Noninvasive determination of healing of major lower extremity amputation: the continued role of clinical judgment

Various tests are used preoperatively to differentiate patients who require an above-knee amputation (AKA) from those whose vascular supply is adequate to heal a below-knee procedure (BKA). This 15-month study of 109 amputations compared four of these methods: segmental Doppler systolic pressure measurements, transcutaneous oxygen measurement (tcPO2), fluorescein angiography, and skin thermometry. There were 66 BKAs (85% healed primarily) and 43 AKAs (93% healed primarily). The actual level of amputation was determined by the operating surgeon without consideration of the preoperative test results, and the incidence of healing was then related to the test parameters. The average skin temperature at the amputation site was higher (93.7 degrees F) in the group that healed primarily compared with those who required operative stump revision (89.9 degrees F) (p less than 0.001). The mean midcalf tcPO2 was also higher in the BKA group that healed (PO2 = 36.6 mm Hg) compared with those who failed (PO2 = 16.4 mm Hg) (p less than 0.001). Qualitative skin fluorescence was less successful in differentiating success from failure. Of the 63 BKAs that fluorescein predicted would heal, eight failed (13%). Doppler pressures at the thigh, popliteal, midcalf, or ankle level were unreliable in predicting healing of a BKA. Formulation of indexes relating absolute pressures to the brachial systolic pressure did not improve the value of this examination. From this review it is concluded that the skin temperature and tcPO2 obtained at the site of proposed amputation were the most reliable prognostic noninvasive examinations.(ABSTRACT TRUNCATED AT 250 WORDS)