Interdisciplinary perspectives of rehabilitation in adult brachial plexus palsies

The aim of this study is to demonstrate that the interdisciplinary approach could have a positive result on the rehabilitation program in brachial plexus paralysis in adults. The prevalence of brachial plexus injuries is currently increasing worldwide, mainly due to the growing number of car accidents, extreme sports or work-related injuries. In this study we chose to present an analysis of one complex surgical case of brachial plexus paralysis, with clinical and electrophysiological investigations. (1) Background: Current reconstructive surgical nerve transfer procedures aim to rehabilitate elbow flexion in such cases. Surgical strategies are based not only on clinical evaluation or investigations by magnetic resonance imaging but also on classical electrophysiological methods, such as electromyography (EMG). (2) Methods: Along with the other types of therapies already established, in the case of this pathology, Transcranial Magnetic Stimulation (TMS) is also used, which provides valuable information about cortical reorganization models concomitant with surgical procedures for nerve reconstruction in the last 3 decades. (3) Results: The study shows that interdisciplinary leads to a faster and more complex rehabilitation of the patient with brachial plexus paralysis and that electrophysiological signals could predict constant motor benefits when associated with rehabilitation programs. Keywords: brachial plexus; electromyography; transcranial magnetic stimulation; neuroplasticity;

Improving flexor tendon gliding by using the combination of carboxymethylcellulose‑polyethylene oxide on murine model

The current approach to flexor tendon injuries is complex and is no longer limited to suturing techniques. Strategies for improving hand function currently include rehabilitation protocols, appropriate suturing materials and techniques, changing the gliding surface by using lubricants and providing growth factors. One product, originally used in spinal surgery, has been shown to be effective in preventing postoperative adhesions. It is a combination of carboxymethylcellulose and polyethylene oxide-Dynavisc^® (FzioMed, Inc.). The aim of the present study was to test the effect of Dynavisc^® on acute injuries of the intrasynovial flexor tendons in the prevention of postoperative adhesions and the improvement of functional results. The study was performed on 20 Wistar rats distributed in two groups. The control group, represented by 10 rats, in which after the reconstruction of the flexor tendon, the peritendinous area was injected with saline solution and the study group, in which the peritendinous area was injected with a single administration of the lubricating gel, Dynavisc^® (carboxymethylcellulose and polyethylene oxide). At 4 and 12 weeks, the rats were sacrificed and tissue biopsy consisted of tendon fragments and adjacent tissue. The evaluation of the results was performed by measuring the adhesion score and observing histological parameters. The presence of important adhesions was found in the control group compared with the group treated with Dynavisc^®, where a supple and smooth tendon, with significantly fewer adhesions were found. The differences between the two groups were significant, thus indicating the efficiency of the lubricant in preventing adhesions. This study supported the important role of Dynavisc^® in the regeneration of the tendon and the peritendinous structures, by limiting aberrant fibrous proliferation in the regeneration process and helping to build a peritendinous space.

The significance of erythropoietin and insulin administration on survival of fat tissue after autologous fat transplantation in Wistar rats. An experimental study

Autologous fat transfer is widely used by plastic surgeons for aesthetic and reconstructive purpose, but it has a great disadvantage because of its high variability rate of resorption. Numerous studies have examined the use of different agents to increase the viability of fat grafts. The results were discouraging because the use of a single angiogenic factor to stimulate fat graft angiogenesis may be inappropriate. We proposed to use two pharmacological factors, erythropoietin (EPO) and insulin (INS), in order to decrease the resorption rate, to improve graft vascularization, and to reduce the number of complications. Twenty-four Wistar male rats were randomly divided in four groups (I–IV) of six animals each. The rats belonging to control group were given autologous transfer of simple fat. In group II, the graft was improved with EPO, in group III with INS, and in group IV both pharmacological agents were administered. Histological evaluation of the grafts at two months after injection demonstrated adipocyte survival in all four groups. The volume of the graft has progressively decreased in all groups and the difference in graft volume at one and two months after transplantation was not significant. The highest maintenance of fat graft volume (95%) at two months was observed in group IV, followed by group II and group III. Necrotic cystic changes and increased fibrosis were most extensive in the control group. The combination of INS with EPO may have a synergistic and additive effect. Efficient administration and dose optimization of these growth factors are important things to consider in the future.

Prolonging Nerve Grafts Using Chemical Extracted Muscle-in-vein with Vein Window Method Chemical acellular nerve grafts

Nerve injuries are a common pathology in hand trauma. The consequences are drastic both for patients and doctors/medical system. In many cases direct coaptation is impossible. A nerve graft should be used in the case of a neuroma, trauma or tumor, for restoration of nervous influx. The aim of this study is demonstrate that by grafting restant nerve stumps with muscle-in-vein nerve grafts we obtain good result in terms of functional and sensibility recovery and also our method �window-vein� is a good way of prolonging nerve grafts. The method of study is experimental. We worked in the laboratory in optimal conditions for carrying out of muscles-in-vein nerve grafts (nerve grafts size 1.5 cm-3 cm). We used acellular muscle grafts with the chemical extraction method.The study was conducted on experimental animals (Wistar male rats).We used 30 experience animals in 3 equal groups (classical group and muscle-in-vein nerve grafts-2 nerve grafts of 1,5 cm central sutured and the third group with muscle-in-vein nerve grafts, window-vein method, 3 cm). At 4 and respectively 6 weeks postoperative at the quality tests we observed the progress with the footprint test. The operated hind in comparison with the healthy hind was 86% recovered and similar with classic nerve grafts. Quantitatively the number of regenerated axons in the group with muscle-in-vein nerve grafts was significant bigger in comparison with the classical group (15%).The method using muscle-in-vein nerve graft with windows-vein it�s a good alternative for nerve grafting in comparison with classical nerve grafting. When the local possibilities are limited, this method is good for prolonging the grafts. The relationship between cost and benefit in this case it�s an advantage because we use the local resources of the affected area. The motor results of nerve grafting ingroup 2 in comparison with group 3 were similar and in some cases better in group 1. Grafting with MVNG offers a better alternative for donor site regeneration in comparison with classical nerve grafts. This method is useful to prolong nerve grafts without adding morbidity.

[Surgical treatment of tarsal tunnel syndrome in diabetic neuropathy]

Posterior tibial nerve decompression surgery in tarsal tunnel syndrome in patients with diabetic neuropathy reduces pain, improves sensitivity and prevents foot ulcers and lower leg amputations.

AIM

To observe and assess the recovery of plantar sensitivity recovery and the healing of ulcerative lessions of the foot, by clinical examination, exploration and analysis of quantitative neurosensory by surgical decompression of the tarsal tunnel.

MATERIAL AND METHODS

We evaluated a total of 10 patients and 12 symptomatic diabetic neuropathy feet in a prospective clinical study, surgically treated in the Clinic of Plastic Surgery and Reconstructive Microsurgery Iaşi, during January 2008 - June 2011, where we practiced tibial nerve decompression and neurolysis in tarsal tunnel syndrome.

RESULTS

Gender distribution of patients in the study group was predominantly male (60%), the ratio M/F = 1.5/1. Posterior tibial nerve decompression surgery resulted in recovery of plantar foot sensitivity in 90% patients in the study group. Testing Semmes-Weinstein 10 g monofilament was positive in 83.3% of the feet preoperatively whereas postoperatively only 25%, distribution of statistically significant (chi2 = 6.04, GL = 1, p = 0.014). Postoperative score to test a range of Riedel-Seiffer returned to normal in all patients: score 7 to 58.3% and score 8 to 41.7% of total standing tested.

CONCLUSIONS

Tarsal tunnel decompression in diabetic patients with peripheric neuropathy improves plantar sensitivity, leads to healing of ulcerative plantar lesions and improves quality of life and should be performed in all patients with diabetic peripheral neuropathy in which conservative and/or medical treatment failed.

[Functional reeducation of flexor tendons with associated lesions in zone II--comparative study]

Regaining satisfactory digital function after flexor tendon laceration and repair has long been one of the most important problems in hand surgery. But optimal therapy is often difficult to ascertain, given the plethora of immediat postoperative protocols published in the scientific literature.

AIM

The purpose of this study is to compare the functional results between Kleinert, Silfverkiöld, Gratton and Strickland protocol towards evaluate them by interconnection and with the literature.

MATERIAL AND METHODS

The prospective study enorolled 75 patients who presented in our cabinet consecutives during 1.05.2008-1.12.2010. The subjects were evaluated regarding Total active motion test and Grip strenght test at 12 weeks postoperative.

RESULTS

We found the best results to Gratton group, followed by Strickland, Silfverkiöld-May and Kleinert groups.

CONCLUSIONS

We conclude that, for the tendinous lessions with associated injury (nervs and vessels) in zone II, our first therapeutical indication is to use the Gratton protocol.

Results in brachial plexus palsy after biceps neuro-muscular neurotization associated with neuro-neural neurotization and teno-muscular transfer

None of the currently used techniques for elbow flexion recovery in brachial plexus recovery offers enough strength for normal life activities. The association between several methods grants a better result by a summarizing effect compared to each method used separately. The paper reveals the improvement of the functional results in brachial plexus reconstruction by combining the techniques of nerve repair (nerve grafts, nerve transfers or direct muscular neurotization) with palliative muscular transfers. Of the 54 cases of microsurgical reconstruction of brachial plexus palsy, in 20 cases we associated a muscular transposition: 7 latissimus dorsi transfers (5 monopolar and 2 bipolar), 5 pectoralis major and 8 triceps transfers. The direct neuro-muscular neurotization of the biceps-EMG efficient - was associated with a muscular transfer in 8 cases: in 4 of the 7 latissimus dorsi transfers, in 3 cases of triceps transfer and in 2 case of pectoralis major transfer. The association of the 3 methods - direct neuromuscular neurotization, neuro-neuronal neurotization and muscular transfer - has a summarizing effect in the flexion restoration of the elbow flexion, which represents a major problem in the brachial plexus palsy.

The treatment of the sacral pressure sores in patients with spinal lesions

Sacral pressure sore treatment requires a multidisciplinary approach, the surgical procedures following nutritional and medical status rehabilitation, spasticity control and sepsis treatment. Serial surgical debridement might also precede flap coverage. Gluteal flaps design such as rotation, transposition or V-Y advancement is selected according to the shape and size of the sore. Our experience with 74 patients with 95 flaps includes 38 rotation flaps, 28 V-Y and 8 transposition flaps. Twenty one patients had bilateral gluteal V-Y flaps. Only 2 transposition flaps had marginal necrosis that healed per secundam. Delayed healing occurred in 12 cases due to sepsis, that healed spontaneously in 10 cases and required surgical reintervention for excision and flap reposition in 2. Prolonged bed immobilization, postoperative antibiotic therapy and late suture removal are important factors in surgical success.

[The radial (Chinese) flap in hand surgery]

The radial (Chinese) flap is an fascio-cutaneous flap raised on the volar aspect of the forearm based on the radial pedicle axis which can be used either pedicled or by microsurgical free transfer. In hand and thumb reconstruction, it is used as an island flap vascularized by a reverse flow from the ulnar artery via the palmar arch, keeping the pivot point at the snuff box level. The possibility to raise a composite flap with vascularized bone or tendons make the chinese flap very useful in hand reconstruction. Of the 35 cases presented, there were 30 pedicled and 5 free flaps from the opposite forearm. The island flaps were reverse flow in 30 cases and with proximal pedicle in 5. In 4 cases the flap contained flexor carpi radialis longus tendon, and in 2 cases a bone graft from the radius. The five free radial flaps transferred from the contralateral side were used as flow-through flap. There were no vascular complications. The advantages and disadvantages of the methods are discussed.

[Hand reconstruction by microsurgical free toe transfer]

Reconstruction of complex hand mutilations with multi-digital or thumb amputations are best treated with microsurgical toe transfers. We present the results of the first 15 cases operated by the first author, of which 12 are thumb reconstructions (6 great toe and 6 second toe transfers) and 3 long fingers reconstructions with combined second and third toe transfers. There were no microsurgical complications. Cortical integration and functional integration was achieved for all transferred toes, with discriminatory sensibility (m2PD between 5 and 13 mm) and active mobility range between 30 and 60 degrees.

[A free microsurgical transfer of a radial (Chinese) flap in reconstructing the lower limb]

The microsurgical transplantation of the radial flap to the hind limb has as main advantages to offer a good quality and sensitive skin cover, the possibility to use the flap's radial artery as a vascular bypass and to raise composite flaps with tendon or bone in case of complex reconstruction.

MATERIAL AND METHODS

The authors present 9 free radial flap transfers to the foot. Patients' ages ranged from 22 to 50 years. Flap dimensions varied between 7 x 5 cm and 12 x 9 cm. Two flaps contained the flexor carpi radialis tendon to reconstruct the Achilles' tendon and one flap included a bone graft from the radial shaft to resolve a bone defect in the second metatarsal. All flaps were reinnervated by suturing the antebrachial cutaneous nerve of the flap to a cutaneous nerve in the recipient site.

RESULTS

There was only one failure in an extensive crush injury. We recommend the radial flap in reconstructing complex defects for it's versatility and for the fact that it can include all types of tissue that may be necessary.