bluuebunny/crossref_metadata_2025 huggingface dataset:
Results of Major Upper Extremity Replantation or Revascularization
Authors: Lee Jung Eun , Lee Young Ho , Baek Goo Hyun
Published: September 2016

Objectives: Major upper extremity replantation is defined as replantation of limbs proximal to the wrist. Advancements of microsurgical techniques and equipment have improved functional results of major replantations. The goal of the treatment is to obtain a nearly normal functioning extremity with an acceptable cosmetic result. This study is to review our experience with major upper extremity replantations or revascularizations after complete or incomplete amputation injury performed from 2000 to 2013. This report provides an indirect comparative analysis of the functional results after major replantation versus previously published reports of arm transplantation in upper extremity. Materials and Methods: Twenty-five consecutive patients who underwent major upper extremity replantations or revascularizations were evaluated retrospectively in this study. The mean age at the time of surgery was 35.6 (range, 14-70) years. The mean follow-up was 34.4 (range, 7-85) months. There was no bilateral amputation. There were 4 complete amputations and 21 incomplete amputations. The mechanism of injury was crush-avulsion in 5, guillotine or deep laceration in 16, crush in 2, and avulsion in 2. There were 8 shoulder and upper arm level, 7 elbow and forearm level, and 10 distal forearm and wrist level amputations in upper extremities. Functional results were assessed using the Korean version of the Disabilities of the Arms, Shoulder and Hand (DASH) and the Chen criteria. Results: The mean ischemic time was 380.1 (range, 120-600) minutes. A total of 23 of 25 limbs survived. There were no significant differences in ischemia time between the 2 groups of patients with respect to limb survival. ( P = .273) The type of amputation and level of injury had no significant association with limb survival ( P = .65 and P = .076, respectively). In the upper extremity, the mean 2-point discrimination test result was 7.7 (range, 4-15) mm, mean visual analog score was 2.91 (range, 1-7), and mean DASH score was 13.2 (range, 2-85). When analyzed by the Chen criteria, there were 15 grade I, 3 grade II, 3 grade III, and 2 grade IV results. One of 2 patients with reperfusion events had proximal amputation. None of the patients developed nonunion or osteomyelitis. Twelve of the successful 23 replants underwent at least 1 secondary procedure. Ten of the successful replants had pain or cold intolerance, but improved with time, and all used the replanted arm for daily activities. Conclusions: The promising results achieved in our major upper extremity replantation or revascularization patients, which was in some respects superior to those in arm transplantation patients, lead us to recommend that replantations or revascularizations continue to be considered as first-line treatment.
A Pedicle Flap Based on the Middle Dorsal Branch of the Proper Digital Artery for Tissue Defects in Fingertip
Authors: Zhou Xiang , Qin Jun , Li Xiang Rong , Sun Yu Cheng , Tang Jin Bo
Published: September 2016

Objectives: We report our experience in using a perforator island flap based on the middle dorsal branch of the proper palmar digital artery for repairing fingertip defect and analyze the clinical outcomes in 25 patients. Methods: Between January 2014 and July 2015, we repaired soft tissue defects of 25 fingers, including 10 index, 4 middle, 5 ring, and 6 little fingers, using this pedicle perforator flap. The middle dorsal branch of the proper palmar digital artery was dissected out and was used as the pedicle with fascia tissue of about 5 mm preserved surrounding the pedicle to ensure venous return. The donor located on the dorsal aspect of the proximal phalanx. The defects in the fingertip were pulp defects on the volar or lateral sides, mostly involving the bone or with bone exposure. Donor site was covered with full-thickness skin graft. The flap survival rate and hand function recovery were analyzed. Results: All flaps survived completely. The patients were followed up for 6 to 18 months. The blood circulation, thickness, skin texture, and the color of the transferred flap match those of normal fingertip. The static 2-point discrimination of the flap ranged from 8 to 11 mm. Minor or mild extension contracture of the distal interphalangeal (DIP) joint was noted in most cases, but no severe scar contracture of the DIP and proximal interphalangeal (PIP) joints. Conclusions: We found that the perforator island flap based on the middle dorsal branch of the proper palmar digital artery is an additional good option of distal finger soft tissue repair. The merit of this flap is no sacrifice of the proper digital artery and close proximity of the donor to the fingertip. The vascular supplies to this flap are reliable for a pedicle perforator flap transfer based on our experience.
A Treatment Algorithm for Correcting Extensor Lag in Vascularized Toe Proximal Interphalangeal Joint to Finger Transfers
Authors: Lin Yu-Te , Loh Charles , Wei Fu-Chan
Published: September 2016

Introduction: To improve the arc of motion (AOM) and reduce the extension lag of vascularized toe proximal interphalangeal joint (PIPJ) transfers, simultaneous reconstruction of the extensor mechanism as part of the transfer has been mentioned in our preliminary report. According to diverse tendon conditions of the recipient fingers and donor toes, we rationalize 3 procedures used to reconstruct the extensor mechanism in vascularized joint transfers (VJTs). These include (1) centralization of lateral tendons when intrinsic hand muscles are non-functional, (2) central slip reconstruction when type I toes* are encountered, and (3) direct extensor digitorum longus (EDL)-to-extensor digitorum communis (EDC) repair for type II toes*. In this study, we evaluate the outcomes of VJTs reconstructed using these techniques and propose an updated treatment algorithm based on our findings. Materials and Methods: VJT was performed in a consecutive series of 26 digits in 25 patients (20 males and 5 females). The average age was 30.5 years. There were 14 right hands (dominant) and 12 left hands. Reconstructed digits included 8 index, 10 middle, and 8 ring fingers. Techniques of simultaneous extensor reconstruction included 8 centralization of lateral bands, 5 direct EDL-to-EDC repairs, and 13 central slip reconstructions. Similar protocol of postoperative rehabilitation was applied to all the patients. Results: The patients were followed up for an average of 16.7 months. The overall AOM and extension lag of the reconstructed PIPJ were 57.7° and 17.9° (81.7% functional usage of pretransferred toe PIPJ AOM), respectively. No significant difference in the results was found between the handedness ( P = .23) and between different recipient fingers ( P = .37). Comparing the outcomes of different extensor reconstructions, the extension lag after centralization, direct EDL-to-EDC repair, and central slip reconstruction were 19.4°, 13°, and 18.8° ( P = .42), respectively; The PIPJ AOM was 54.4°, 55°, and 60.8° ( P = .42); the final finger PIPJ AOM compared to the pretransferred toe PIPJ AOM was 76.3%, 79.7%, and 85.9% ( P = .34). Discussion: Due to the varied recipient finger conditions, no single technique is suitable for every scenario. Careful evaluation of recipient finger and toe tendons is required to perform the most appropriate extensor reconstruction. Using our treatment algorithm, consistent outcomes can be produced with reduced extensor lag and maximum usage of potential toe PIPJ AOM. As such, customized extensor mechanism reconstruction is important to improve the outcomes of vascularized toe PIPJ transfers.

*In our clinical observations, the majority (>86%) of second toes do not have a strong, definite insertion of central slip at the base of middle phalanx (type I). On the contrary, less than 14% of second toes do have.
Which Nerve to Use? Comparison Between Donor Nerves to Motorize the Free Functional Gracilis Muscle Transfer for Elbow Flexion in Traumatic Brachial Plexus Injuries
Authors: Cho Alvaro Baik , Pisani Marina Justi , Silva Gustavo Bersani , da Costa Raquel B. Iamaguchi , Torres Luciano Ruiz , Alves Jairo , Mattar Rames , Wei Teng Hsiang , de Rezende Marcelo Rosa
Published: September 2016

Introduction: Elbow flexion deficit is a frequent problem in traumatic brachial plexus injuries and reestablishment of this function is the primary treatment goal. When management is delayed or the initial acute approach fails, free functional transfer of the gracilis muscle for elbow flexion is the treatment of choice: the authors seek to determine which donor nerve (spinal accessory, intercostal, median, or ulnar) results in better elbow flexion after microsurgical reconstruction. Methods: Retrospective analysis of patients with traumatic brachial plexus injuries who underwent functional free gracilis muscle flap for elbow flexion between February 2003 and October 2014 was carried out. Postoperative function of the gracilis functional flap was recorded and patients were divided into 4 groups according to donor nerve: spinal accessory nerve (SAN), intercostal nerves (ICN), motor fascicles of the median (MED), and ulnar nerve (ULNAR). Cases in which a primary neurorrhaphy was not possible were further subdivided into 2 groups: SAN with graft interposition (SAN graft) and ICN with graft interposition (ICN graft). The final elbow flexion strength was evaluated by the British Medical Research Council (BMRC) scale and time in months when the authors first observed M3 muscle power was also of note. Results: Fifty-nine patients met inclusion criteria for this retrospective study. Two cases were excluded due to flap loss (3%) and 3 were lost to follow up (5%). Of the 54 patients enrolled, 53 were males (98.2%) with a mean age of 29 years. The mean follow-up period was 28 months. Thirty-four cases obtained muscle strength of ≥ M3 (62.9%), 6 M0 (11.1%), 4 M1 (7.5%), 10 M2 (18.5%), 13 M3 (24%), and 21 M4 (38.9%). The mean interval to first recorded M3 muscular strength was 16 months. Patients stratified by donor nerve achieving ≥ M3 had the following distribution: SAN 83.3% (15/18), SAN graft 50% (2/4), ICN 50% (2/4), ICN graft 33.3% (1/3), MED 40% (2/5), and ULNAR 60% (12/20). No statistical difference for final muscle strength was found between donor nerve groups. SAN transfer with graft interposition took longer to reach muscle strength of M3 or greater ( P < .05). Conclusion: Free functional gracilis muscle flap for traumatic brachial plexus injuries is a viable option for elbow flexion recovery. Comparison between 4 different nerve transfers—SAN, ICN, MED, and ULNAR—did not clearly indicate a better alternative over the others.
Free Vascularized Fibular Graft With LISS Plate for the Bone Defects of the Femur After Tumor Resection
Authors: Lee Young Ho , Kim Jihyeung , Lee Seung Hoo , Park Jin Woo , Kim Kahyun , Baek Goo Hyun
Published: September 2016

Background: Various methods for reconstructing large femur bone defects after tumor resection have been introduced. In this study, we reviewed the clinical outcomes of using a one-barrel free vascularized fibular graft (FVFG) protected by a less invasive stabilization system (LISS) plate for lesions not involving the joint. Methods: Between August 2007 and August 2013, we treated 7 patients with large femoral bone defects after tumor resection. The mean age of the patients was 19 years (range, 12-36 years), and 3 were women. All were diagnosed preoperatively with osteosarcoma. Femoral bone defects were reconstructed using an in-lay strut FVFG following a LISS femoral plate. The mean bone defect size was 10.5 cm (range, 6-16 cm). We reviewed clinical outcomes at the last follow-up. Result: All patients survived beyond the last follow-up; the mean follow-up period was 54 months (range, 26-100 months). Two patients (28.5%) sustained stress fractures of the FVFG, but the LISS plate protected the fractured graft until in situ bone healing occurred. One case of metal failure of the LISS plate was encountered; the plate was replaced with a longer one, which achieved bone union. Mean time to bone union of both host-graft junctions was 24 months (range, 18-31 months). The mean Musculoskeletal Tumor Society score (%) was 85.8% (range, 80-95%). Conclusion: A one-barrel FVFG protected by a LISS plate maintained a stable graft-host bone construct, successfully leading to bone union, even in cases of stress fractures of the graft, and appears to be a good option for large femur bone defects after tumor resection.
An Anatomical Feasibility Study on the Use of the Hypoglossal and Hemi–Hypoglossal Nerve as a Donor Motor Nerve for Free Functioning Muscle Transfer in Upper Extremity Reconstruction
Authors: Dagum Alexander B. , Guillen Phillip , Lu Yi-Hsueh
Published: September 2016

Objective/Hypothesis: Reconstruction of adult brachial plexus injuries remains a clinical challenge. The advent of nerve transfers and free functioning muscle transfers has increased the available reconstructive options in particular when there have been root avulsions. The accessory, intercostals, and phrenic nerves have been the most common donor nerves used to reanimate free muscle transfers. However, it is not uncommon for these patients to have sustained multiple rib fractures or a phrenic nerve avulsion precluding the use of either nerve as a donor. The paucity of currently available donor motor nerves for transfer led us to investigate the hypoglossal and hemi–hypoglossal nerve as a potential donor nerve for a free functioning muscle transfer. The hypoglossal and hemi–hypoglossal nerve have been used successfully as a nerve transfer for the facial nerve and with some success as a nerve transfer with nerve grafts to the musculocutaneous nerve in obstetrical brachial plexus palsy. We postulated that the hypoglossal and hemi–hypoglossal nerve could be used for nerve transfer without nerve grafts for innervation of a gracilis or latissimus dorsi muscle for elbow flexion in upper extremity reconstruction. To our knowledge, this has not been studied before. Materials and Methods: In 12 formalin-embalmed cadavers (6 males and 6 females), the hypoglossal, thoracodorsal, and obturator nerve branch to gracilis was dissected bilaterally and their respective lengths from their origin to the muscle measured. The distance from the lowest point of the hypoglossal nerve in the neck to the lateral third of the clavicle was measured. Results: The average distance from the lowest point of the hypoglossal to the lateral clavicle was 8.4 ± 1.3 cm in males and 7.7 ± 0.8 cm in females. When the hypoglossal was transected distally and brought down, the average distance to the clavicle was 4.5 ± 1.6 cm in males and 3.8 ± 1.5 cm in females. The average length of the nerve to the gracilis was 13.1 ± 1.6 cm in males and 12.4 ± 11 cm in females and of the thoracodorsal nerve 14.9 ± 1.5 cm in males and 14.0 ± 1.0 cm in females. Conclusion: This cadaveric study demonstrates that the hypoglossal and hemi–hypoglossal nerves may be used as potential motor donor nerves by direct nerve transfer without the need for nerve grafting to innervate a free functioning gracilis or latissimus dorsi muscle for upper extremity reconstruction.
Evaluation of Elbow Flexion Gain in Patients With Upper Brachial Plexus Injury Using Neurotization of Ulnar Nerve to Free Gracilis Muscle
Authors: de Rezende Marcelo Rosa , Mattar Rames , Torres Luciano , Hsiang Teng , Cho Alvaro Baik
Published: September 2016

Objective: The primary objective of our study was to evaluate the results of the free transfer of the gracilis muscle with neurotization in the ulnar nerve to recover the elbow flexion strength in patients with upper brachial plexus injury. Methods: We performed retrospective study that evaluated 21 patients with upper brachial plexus injury. The patients underwent surgical treatment free transfer of the gracilis muscle (21 patients, the free group) for elbow flexors with neurotization in part of the ulnar nerve. The primary outcome was evaluated using the scale defined by The British Medical Research Council (BMRC) and a minimum follow-up of 12 months was defined. The BMRC scale classifies muscle strength from M0 (no contraction) to M5 (normal strength). We used the criteria of M4 or more to classify the elbow flexion as a good result. Results: The ability to obtain an M4 score or higher was 61.9% in the free groups. Considering the possibility of an M2 score or higher, which would allow for complementary surgery, 95.2% of patients in the free group obtained this score. Conclusion: The free transfer of the gracilis muscle and neurotization in the ulnar nerve in patients with upper brachial plexus injury showed satisfactory results considering the elbow flexion strength.
Is the Use of Humeral Tourniquet Painful During Peripheral Local Anesthesia?
Authors: Babas Geza , Urban Ferenc , Czinke Zoltan , Rimaszeki Zsolt , Bajdik Beata , Szabo Zsolt
Published: September 2016

Purpose: Tourniquet is frequently used in hand surgery. Metabolic changes caused by ischemia has been widely studied and published. Our aim was to study the tourniquet related pain from the patient prospective. Materials and Methods: A prospective study was performed in our unit involving 312 patients. The type of operation, the form of anesthesia, and the duration of the procedure was registered, and the patient was asked about pain caused by the tourniquet, the operation, and the preparations for the procedure. The evaluation of the pain was done using a Visual Analogue Scale (VAS) of 1 to 10. The VAS form was filled 3 times for each patient: 2 hours, 1 day, and 1 week after the procedure. Results: Five patients were excluded from the study due to some administrative deficiencies. Finally, 921 data sheets from 307 patients were analyzed The overall pain level, caused by the whole procedure, was 2.71 points 2 hours after the procedure for patients in regional anesthesia (peripheral nerve block, distal to the tourniquet) and 1.62 points for the patients in general anesthesia. One week later, they remembered the pain as 2.17 points for blocks and 1.08 points for general anesthesia. In patients who had nerve block, the tourniquet caused pain was 2.61 in average, with 3.20 after the operation, presenting a peak of 4.7 points on the next day for procedures longer than 30 minutes. A week later, they remembered a pain of 2.88 points with no difference in relation with the length of the operation. Discussion: Our study showed that tourniquet can be used for hand surgical operations even in case of peripheral nerve blocks. Interventions shorter than 30 minutes were supported without major complaints. Longer operations needed some drug supplementation (fentanyl, dormicum). All our patients could support the tourniquet with minimal inconvenience. Comparing the pain caused by the anesthetic preparations (3.2), and the procedure itself (2.1), the pain caused by tourniquet (2.9) can be rated to be acceptable in our daily routine.
The Septic Hand
Authors: Bajdik Beata , Rimaszéki Zsolt , Urban Ferenc , Bajdik Beata , Babas Geza , Czinke Zoltan , Szabo Zsolt
Published: September 2016

Aim of the Study: To compare our septic hand cases from 2002 with the septic hand cases from 2012 due to the fact that we have the impression that the number and pathology of septic hand conditions has changed in the last few years. Material and Method: We have retrospectively compared, using the available medical documentation, the surgically treated septic hand conditions from 2002 to 2012: number of patients, localization and extension of the septic process, type of tissue affected (skin, subcutaneous tissue, bone, articulation), and the type of the pathogenic germ. Also, number of days from the first symptoms to surgery, length of hospitalization, and number of days needed for return to work were evaluated. Results: In 2002, in total, 52 septic hand cases were operated in our unit compared with 98 in 2012. The most frequently affected was the index finger on the left hand in both periods. Of all, 60% of the patients were male and 40% female in both periods. In 2002, the most frequently affected tissue was the subcutaneous tissue in 63%, and in 2012, the small joints of the hand in 65%. The pathogenic germs remained unchanged. The number of digital amputations grew from 11% to 16%. The time elapsed from the first symptoms to surgery was in average 12 days for both periods. Number of days spent in hospital decreased from 9 to 7 days, but the final healing occurred in average after 44 days in 2012 compared with 30 days in 2002. Conclusions: The number of septic hand conditions has doubled in 10 years. Interestingly, neither the number of affected fingers nor the pathogenic germs had changed. Localization changed from the subcutaneous tissue to the joints level. This was reflected in the increase of number of amputations and the 30% longer period needed for the final healing. It seems obvious that bigger attention should be addressed to early stages of hand infections to prevent articular involvement and unwanted mutilating outcome.
Comparative Analysis of 2 Methods for Radiographic Angle Measurement
Authors: Patiño Juan M. , Wilson Fernando Zicovich , Abdon Ignacio M. , Hochbaum Sandra D. , Kerber Egar A.
Published: September 2016

Objective: Angle measurement is a key element to orthopedist’s decision making, especially to hand surgeons. Digital x-ray studies are becoming more frequent, but many of the software used for this purpose do not allow us to perform these measurements. The aim of this study is to evaluate the effectiveness of a method for angle measurement using Microsoft PowerPoint (pp-method), worldwide popular software, compared with traditional measurement with a goniometer. Materials and Methods: We used 50 normal wrist x-ray studies, anterior-posterior and lateral views, randomly selected from a digital archive. Four observers (two hand surgeons and two fellows) performed one series of measurements of the radial tilt (RT) and volar tilt (VT) angle of the distal radius. These measurements were performed by two different methods: with a traditional goniometer (g-method) and by the method described by J. K. Jones et al using pp-method. Measurements were analyzed, and both methods were compared by an analysis of variance (ANOVA). A significance level of 5% was considered. At the same time, kappa index was calculated to evaluate the agreement between observers in each variable by each method. As the kappa index is calculated for variables in categories, two groups were considered: those above and over the median (23.5° for RT and 10° for VT). Results: According to ANOVA, statistical analysis shows that the difference between methods is not significant ( P value < .71 for RT, < .70 for VT). The 95% confidence interval (CI) for g-method is (22.4°-24.1°) for RT and (8.56°-10.79°) for VT, and for pp-method, it is (22.5°-24.2°) for RT and (8.67°-10.9°) for VT. Variation between observers represents 2% of total variation for RT and 1% for VT. Kappa index for g-method and RT variable (g-RT) is 0.426, for pp-RT method is 0.40, for g-VT method, it is 0.371, and for pp-VT method, it is 0.30. Conclusion: Statistical analysis shows that all the observers have the same behavior against both methods ( P value < .82 for RT and < .85 for VT). However, kappa index shows that the agreement between observers is acceptable and that the differences between them represent, at most, 2% of the total variation. According to the results obtained, and having observed that there is no significant difference between traditional measurement with goniometer and the method we proposed to study, we believe that this is a valid and useful tool for radiologic measurement for those orthopedists who do not have a software designed for this purpose. The advantage of having Microsoft PowerPoint in most of the computers of the world makes this method an even more seductive choice.
Minimally Invasive Treatment of Dupuytren
Authors: Baur Eva-Maria , Zimmermann Robert , Muller Verena , Mair Waltraud
Published: September 2016

Objective / Hypothesis: At our clinic of plastic, reconstructive and aesthetic surgery we are looking for the results after two minimally invasive treatments for Dupuytren disease. With the upcoming possible treatment with collagenase the l”old fashioned” therapy with percutaneous needle fasciotomy (PNF) becomes a big revival. The purpose of the non-randomized prospective study was to Iook for differences after 12, 18 and 24 months regarding the two possible treatments. Methods: ln our clinic we propose and perform both treatments, the decision is taken together with the patient. Since more than 2 years we follow-up the patients regarding the results after 3 weeks, 3, 6, 12, 18, 24 months; regarding function, scars, and recurrence (worsening of contracture in comparison to 3 weeks postop at least for 20°). Patients treated with Xiapex: 12 months postop. - 25 patients; 18 months postop. - 16 patients; 24 months postop. -13 patients. PNF: 12 months postop. - 30 patients; 18 months postop. - 19 patients; 24 months postop. - 18 patients. Post I { operative” treatment is night-splinting for 6 weeks at least. Results: We report our results of both groups. We cannot find a real difference between both groups. But the follow-up is only 24 months for the moment. We report also the pros and cons of the two different treatment options. Conclusions: Both minimal invasive treatment options are very similar in results and complications with a slight advantage for the percutaneous needle fasciotomy. But a longer follow up and a bigger study is required.
Revision Arthroplasty of the Wrist
Authors: Fischer Per , Pettersson Kurt , Sagerfors Marcus
Published: September 2016

Purpose: Management of failed total wrist arthroplasty (TWA) can be challenging, and treatment options include salvage arthrodesis or revision arthroplasty. To our knowledge, there are no previously published series on this subject. The aim of the study was to report outcome after revision arthroplasty of the wrist operated at a Swedish referral center. Methods: A cohort of 18 consecutive revision TWAs was evaluated preoperatively, 1 and 5 years postoperatively. Indication for revision arthroplasty was failed TWA. The operations were performed between 2003 and 2015. The primary endpoint was implant survivorship. Secondary outcome measures included visual analogue scale (VAS) pain scores, range of motion, hand grip strength, and functional scoring with Canadian Occupational Performance Measure (COPM). Results: Of the 18 revision cases, 4 were revised after a mean of 4.5 years (range, 3-5 years). Mean follow-up was 6.1 years (range, 1-12 years). Synthetic bone graft was used in 9 cases, allogenous corticocancellous bone graft in 1 case, and cement in 6 cases. Of the revised cases, 1 TWA was removed because of infection and 3 cases underwent total wrist arthrodesis. Range of motion and grip strength was preserved compared with preoperative results. VAS pain score at rest and in activity decreased considerably 1 year (0 at rest; 2.4 in activity) and 5 years postoperative (0.1 at rest; 1.1 in activity) compared with preoperative results (1.5 at rest; 3.8 in activity). COPM performance and satisfaction were improved considerably 1 year (5.9 performance; 6.6 satisfaction) and 5 years postoperative (4.1 performance; 4.3 satisfaction) compared with preoperative results (3.5 performance; 3.1 satisfaction). Conclusion: Revision arthroplasty of the wrist is a motion preserving option to wrist arthrodesis in the management of failed TWA. Good functional outcome can be achieved in selected cases.
Variations of the Pulley System of the Thumb
Authors: Ripoll Guzmán , Jaber Samer , Martinez Fernando , Glumcher Damian , Corderi Fabricio
Published: September 2016

Background: Originally described by Doyle and Blythe, and perpetuated in hand surgery treaties since, 3 pulleys have been described in the thumb: A1, O, and A2. Ever since Schmidt in 1999 showed that these pulleys were only present in 10% of all thumbs, this system has been in revision. Multiple authors have found variations both in the disposition and quantity of elements that form them. Methods: This is an observational study, based on dissection of 17 hands in our human anatomy department. In 3 of the cadavers, only one hand was dissected, due to prior injury or prior dissection without preservation of the pulley system. Under surgical loupes of 3.5 × magnification, we performed a Brunner-type zig-zag incision on the column of the thumb, allowing identification of the thumb’s sheath and pulleys. Two independent investigators determined pulley type and measurement with a manual caliper, with the thumb in extension. The average of both measurements was used. Results: Five pulley types were identified and cataloged according to Schubert’s classification. Type I is the original disposition with an A1 pulley, an oblique pulley, and an A2 pulley. Type II presents an A1, a variable pulley (Av), oblique, and A2, with A1 and Av being parallel. Type III presents A1, Av, oblique, and A2, with A1 and A2 fused. We found a fifth type, with A1, Av, oblique, cruciform, and A2. Our results show type I 11.8% (n = 2), II 17.7% (n = 3), III 29.4% (n = 5), IV 29.4% (n = 5), and V 5.8% (n = 1). Conclusions: From the literature reviewed and our own series, we have found that the classical description of the pulley system is not the most frequent one. As a matter of fact, it represents only 11.8% in our series, with systems in which 4 pulleys were present accounting for 76.7% and 5 pulleys 5.8%. This fact must be accounted for in current hand surgery to avoid misconceptions in thumb anatomy. We believe that accurate anatomical of the pulley system of the thumb may have repercussions for some procedures, such as triggering thumb surgery.
Use of Skin Allograft in Upper Extremity Deep Burns
Authors: Lena Tania , Novello Gabriela , DiStefano Raquel , Torroba Lucía
Published: September 2016

Introduction: Surgical treatment in patients with deep upper limbs diagnosis consists of elimination of nonvital tissue and coverage of resultant wound. Coverage may be definitive or temporal. One common option of temporal coverage is skin allograft, which represents a biological barrier that promotes reepithelialization and generates a matrix to skin autograft if it is necessary. Our Burn Center uses skin allograft from National Cells, Tissue and Organs Donation and Transplant Institute. This institute is in charge of the obtention from cadavers and the processing of this tissue. Objective: General objective is to describe the type of coverage used in patients with diagnosis of upper limb deep burn. Specific objective are to evaluate adhesion time of skin allograft, the percentage of dermis incorporation, and the number of surgical interventions required to reach total coverage of burn wound. Materials and Methods: We present a descriptive and retrospective study, including 50 patients with deep upper limbs burn who required hospitalization in National Burn Center in the period between December 1, 2014 and December 1, 2015. Results: In that sample, 38 where male (76%) and 12 female (24%), with a mean age of 40 years. Thirty patients (60%) required definitive coverage with skin autograft, while in 15 cases (36%) we used skin allograft. When skin allograft was used, 5 cases registered more than 80% adhesion 3 weeks postoperatory. One of those 5 cases had a 100% adhesion with dermis incorporation and reepitelialization. Four cases had an adhesion of skin allograft between 50% and 80% at 3 weeks postoperatory, and 6 patients registered less than 50% of adhesion at 3 weeks. Three of these 6 last cases had 0% of adhesion at 3 weeks. Conclusions: Skin allograft is a frequent option to burn-wound coverage in upper limb burned areas, acting as a biological and mechanic barrier during 3 weeks in 80% of total cases. That makes local treatment easier because it may be done less frequently representing less mobility for the patient and less sanitary costs. Besides, it reduces the risk of complications of burn wound and generates an appropriate matrix to skin autograft if it is required.
The Effect of Subepineural Platelet-rich Plasma on Regeneration of the Sciatic Nerve in a Rat Model
Authors: Fatemi Mohammad Javad , Nasab Mohammad Reza Akhoondi , Forghani Siamak Farokh , Pakfetrat Farzin , Mansouri Kourosh , Niazi Mitra
Published: September 2016

Background: Peripheral nerve injury is one of the most challenging of modern surgical problem. Recent advances in understanding the physiological and molecular pathways demonstrated the important role of growth factors in peripheral nerve regeneration. Platelet-rich plasma (PRP) is a biological product that has many growth factors. The aim of this study was to investigate the effect of PRP in the regeneration of sciatic nerve crush in the rat model. Methods: In this experimental study that established in the animal lab of the Hazrat Fatemeh Hospital in Tehran during September to October 2013, 24 healthy male Sprague-Dawley rats (200-250 g) were randomly divided into two groups. In all rats, the sciatic nerve was cut and then carefully repaired by the tension free method under a light microscope. In group 1, after the repair, 0.05 µL of PRP was injected below the epineurium to the proximal and distal parts of the repaired area. In group 2, the same amount of normal saline was injected to the proximal and distal of the repaired area. After 6 weeks footprint analysis, neurophysiologic and histopathology evaluations were performed. Results: Significant differences existed between the two groups footprint analysis ( P = .001). Also the nerve conduction latency test was significantly shorter in PRP group (1.0233 ms in PRP group and 1.7375 ms in control; P < .001). The average amplitude in the first group and the second group was 7.6250 mv (control) and 6.3667 mv that does not show a statistically significant difference ( P = .093). Significant differences between the two groups in the number of axons of the proximal portion of the study were not seen ( P = .29). The parameters included number of axons of the proximal and the distal part of axons, the diameter of the distal and proximal axons in the two groups was compared. In the two groups, there was statistically significant difference between the above parameters ( P = .298). Conclusion: It seems that PRP may have an important role in peripheral nerve regeneration and functional recovery after nerve laceration and repair. Further clinical evaluation is recommended.
Evaluation of Vitamin D Levels in Women With Carpal Tunnel Syndrome
Authors: Lee Seung Hoo , Gong Hyun Sik , Kim Jihyeong , Baek Goo Hyun
Published: September 2016

Introduction: Studies suggest that vitamin D has a role in neuroprotection. Low vitamin D is related to neuropathy in patients with diabetes, Sjögren’s syndrome and other neurodegenerative disorders. However, no study has been conducted measuring serum vitamin D levels in patients with CTS. The aim of this study was to investigate whether vitamin D status is associated with CTS, by comparing vitamin D levels between CTS patients and healthy control women and between patients with CTS and other upper limb conditions. Methods: Vitamin D levels were compared between carpal tunnel syndrome women (n = 135) and healthy control women (n = 135) or patients with other upper limb conditions (n = 135). Results: There were no differences in vitamin D levels between the patients with carpal tunnel syndrome and the controls. However, women with carpal tunnel syndrome younger than 50 years old had significantly lower vitamin D levels than age-matched healthy control women (P = 0.023) or patients with other upper limb conditions (P = 0.035). When women with carpal tunnel syndrome and healthy control women were pooled, the incidence of carpal tunnel syndrome was higher in vitamin D deficient women than in non-deficient women, especially in those younger than 50 years. Discussions: This study suggests a potential link between vitamin D status and the occurrence of carpal tunnel syndrome in women younger than 50 years but causation is not established.
Functional Outcome After Reconstruction of a Long Nerve Gap in Rabbits Using Optimized Decellularized Nerve Allografts
Authors: Bulstra L. F. , Hundepool C. A. , Bishop A. T. , Hovius S. E. R. , Shin A. Y.
Published: September 2016

Objective/Hypothesis: Processed nerve allografts provide a promising alternative to nerve autografts with the advantages of a readily available unlimited supply, no donor site morbidity, and without the need for immunosuppression. The nerve allografts currently available for clinical use do not provide satisfactory results. The processing technique was optimized to reduce the allografts immunogenicity and cellular debris while maintaining the ultrastructural properties. The aim of this study was to evaluate the functional recovery after reconstruction of a long nerve gap using the optimized nerve allograft in a rabbit model. To study the influence of storage techniques on functional recovery, processed nerve allografts were either cold or frozen stored. The nerve allografts were challenged to the gold standard, the nerve autograft. Materials and Methods: Nerve allografts were decellularized using our optimized protocol and stored at either 4°C or −80°C. In 36 New Zealand White rabbits, a 3-cm peroneal nerve gap was repaired with either a cold or frozen stored processed nerve allograft or a nerve autograft (control). Nerve recovery was longitudinally evaluated with ultrasound measurements performed prior to surgery and at 10, 16, and 24 weeks follow-up. Functional motor recovery was determined 24 weeks postoperatively using electrophysiology (compound muscle action potentials [CMAP]), isometric tetanic force (ITF), wet muscle weight (MW), and histomorphometry. Results: The longitudinal ultrasound measurements showed that the cold stored nerve allograft provides faster and earlier regeneration than the frozen stored nerve allograft. At 24 weeks, the cold stored allograft showed equal results compared with the autograft based on ultrasound measurements. Ultrasound furthermore showed significantly impaired recovery in the frozen stored allograft group compared with both the cold stored allograft and autograft ( P < .05). The functional outcome measurements, MV and ITF, both showed that the cold stored allograft proved to have a similar result compared with the autograft ( P > .05 for both MW and ITF, respectively). The frozen stored allograft, however, had a significantly inferior result to the autograft ( P < .05 for both MW and ITF). The CMAP and histomorphometry results showed no significant differences between all 3 groups. Conclusions: Nerve reconstruction with the cold stored optimized nerve allograft results in successful recovery of a long motor nerve defect in a rabbit model, statistically equivalent to the gold standard nerve autograft. Freeze storage of the processed allograft impairs the functional outcome.
Intraoperative Electrophysiology Examination of Median Nerve Showed the Quick Outcome of Carpal Tunnel Release
Authors: Chen Jie , Xu Lei , Tian Dong
Published: September 2016

Objective: To explore a reliable predicator of surgical outcomes of carpal tunnel release (CTR) by exploring the changes of preoperative and intraoperative median nerve-abductor pollicis brevis compound muscle action potential (CMAP). Methods: Fifteen patients with carpal tunnel syndrome were involved in the study. Electrophysiology examination was carried out to record CMAP of abductor pollicis brevis muscle at following moments: before CTR; right after brachial plexus block; immediately after CTR and tourniquet release; 1 minute, 3 minutes, 5 minutes, and 7 minutes after tourniquet release. Statistics analysis was done to compare these parameters with preoperative values. Results: There were statistically significant changes in both amplitude and latency of the CMAP within 5 minutes after tourniquet release ( P < .05) while not much difference was seen after 5 minutes. Both the latency and amplitude of CMAP greatly improved ( P < .05). Moreover, the improvement of amplitude had more statistical significance ( P < .01). Conclusion: CMAP amplitude is a better predictor than CMAP latency to evaluate the effectiveness of median nerve decompression. It is more reliable to carry out electrophysiology examination at least 5 minutes after tourniquet release.
Nerve Transfer Surgery in Tetraplegia
Authors: Yalcin Nilay , van Zyl Natasha
Published: September 2016

Objective: Spinal cord injury leads to upper motor neuron paralysis below the level of the injury. However, emerging evidence suggests lower motor neuron denervation is evident in these paralyzed muscle groups. We aimed to study patients with chronic cervical spinal cord injuries who underwent nerve transfer surgery for evidence of lower motor neuron dysfunction in the upper limb preoperatively. Methods: Patients with cervical spine injuries who were being considered for nerve transfer surgery were examined using electromyography for evidence of spontaneous activity in the form of fibrillations. The neuromuscular units were divided into clinically functional “donors”—teres minor, brachialis, and supinator—and into clinically low-functional or nonfunctional “recipients”—flexor digitorum profundus (FDP), flexor pollicis longus (FPL), extensor digitorum communis (EDC), extensor pollicis longus (EPL), and triceps. The aim of the nerve transfer surgery was to restore pivotal upper limb functions such as elbow extension, key pinch, grasp, and release. Results: A retrospective review of the preoperative electromyography results for 25 upper limbs from 17 male patients was performed. A significant proportion of the recipient muscles showed evidence of fibrillations: FDP 96%, triceps 92%, and FPL 91%. Incidence of fibrillations for EDC and EPL was significantly lower despite also being in the recipient group. Interestingly, donor muscle groups with volitional control also showed evidence of fibrillations. Although at a much lower rate than most of the recipient groups, the incidence of fibrillations in the donor muscles were as follows: supinator 8%, brachialis 14%, and teres minor 34%. Conclusion: Patients with cervical spinal cord injury show evidence of lower motor neuron injury on electromyography. This finding has implications for the timing of nerve transfer surgery. The authors propose that, to maximize outcomes, prospective recipient muscles demonstrating denervation should be reinnervated using nerve transfers early (6-12 months post injury) before the neuromuscular endplate degeneration that follows denervation occurs. The presence of fibrillation potentials in prospective donor nerves, which are clinically normal on examination, may have implications for the outcome of nerve transfer surgery using these nerves.
The Role of Electromyography in Planning Nerve Transfer of the Upper Limb After Tetraplegic Spinal Cord Injury
Authors: Nassimizadeh Mohammad , Nizar Bafiq , Samson Deepak , Shirley Colin , Power Dominic
Published: September 2016

Objectives: Following tetraplegic spinal cord injury upper limb function may be improved by selective use of peripheral nerve transfers in isolation or in combination with tendon transfers. Early surgery is essential for nerves originating in the injured spinal cord segments due to Wallerian degeneration. Motor nerves arising from the infralesional segment of the injured spinal cord will have an intact peripheral neural pathway and nerve transfer may be undertaken beyond 12 months. This study evaluates the role of electromyography in planning and timing reconstruction. Methods: A consecutive series of 8 patients referred for consideration of nerve transfer surgery for restoration of upper limb function following tetraplegic spinal cord injury were evaluated with electromyography to establish volitional control, denervation, or evidence of reinnervation. For those patients undergoing surgery, further evaluation of intraoperative stimulation thresholds and motor response was recorded using a 4-point scale. Results: At our unit, we established a service for rehabilitation surgery of the upper limb after cervical spinal cord injury in 2013. Electromyography predicts lower motor unit lesions without reinnervation and early nerve transfer intervention may be offered to key target muscles in this group. For the C5/6 level tetraplegic with International Classification of Surgery of the Hand in Tetraplegia (ICHT) function at level 0 to 2, we recommend electromyography of extensor digitorum communis (EDC) and triceps to establish timing of reconstructive nerve transfers. Conclusions: Electromyography is an essential component of the preoperative assessment of patients for nerve transfer reconstruction of the upper limb after spinal cord injury. For the C5/6 level tetraplegic with ICHT function at level 0 to 2, we recommend early electromyography of EDC and triceps between 3 and 6 months from injury to establish timing of reconstructive nerve transfers.
Six-Strand Core Repairs Ensure Early Active Motion and Satisfactory Functional Return of the Flexor Pollicis Longus Tendon
Authors: Pan Zhang Jun , Qin Jun , Zhou Xiang , Li Xiang Rong , Tang Jin Bo
Published: September 2016

Objective: To report outcomes of repair of flexor pollicis longus (FPL) tendon in 23 thumbs followed by early active thumb motion. Materials and Methods: We used a 6-strand repair with very loose epitenon suture for lacerated FPL tendons in 23 thumbs. These patients were treated between January 2014 and May 2015. All patients were repaired primarily in the day of injury or within the first week after injury. The FPL was exposed through a Bruner’s incision, and the tendon was repaired with either a 6-strand M-Tang repair (17 thumbs) using 4-0 looped suture and a 6-strand repair method made of 3 groups of modified Kessler repair (6 thumbs) using 4-0 Ethilon suture. After surgery, the thumbs were immobilized for 3 to 4 days, and active motion was initiated after that. The patient was encouraged to move the thumb interphalangeal joint to about ½ of the total motion range in the first 1 to 3 weeks after repair. Then the patient proceeded to full range of active motion around the end of week 3. Results: All patients were followed for 6 to 19 months with the mean follow-up of 14 months. The functional recovery at the final follow-up was graded according to Strickland criteria. Fourteen thumbs were rated excellent, 4 good, and 3 fair. No thumbs were rated poor. No rupture of the FPL was recorded. The overall excellent and good rate was 86%, and the rate of fair results was 14%. Conclusions: We found that a 6-strand core suture repair is sufficient for early active motion of the repaired FPL tendon. With early active motion, the recovery of the FPL function is usually excellent and good. We found there is no risk of repair rupture with a 6-strand core suture repair. We only used very loosely added 2 or 3 stitches of epitenon suture. We found that adding complex epitenon suture is unnecessary with a strong 6-strand repair for the FPL tendon.