Inside-out vein graft vs autogenous nerve graft in promoting axonal regeneration: An experimental study in a rat model

BACKGROUND: An experimental study was done to compare the efficacy of inside-out vein graft versus autogenous nerve graft as nerve conduit in promoting axonal regeneration in a rat model.METHODS: The study used 16 Spraque-Dawley rats randomly divided into two groups: the inside-out vein graft group and control group (autognous nerve graft). The outcomes measured were histomorphology (axon number and diameter), muscle twitch response (amplitude) and the walking track analysis at 2, 4 6 and 8 weeks.RESULTS: The inverted vein graft and control groups showed similar axon diameter (P=0.76), and axon number (P=0.85), weeks and similar muscle twitch responses (P=0.87) after eight weeks. The walking track analysis showed no significant difference between the two groups at eight weeks.CONCLUSION: The study showed that the inside-out vein graft group had similar motor recovery as compared to control group based on the muscle twitch analysis and walking track analysis in a rat model.In terms of histomorphometric analysis, the two groups were similar in terms of axon diameter and axon count.

Investigation on the level of evidence in researches done by orthopedic residents of the Department of Orthopedics, Philippine General Hospital over the past twenty-seven years

BACKGROUND: Clinical research has been part of the orthopedic residents' training program over the past 27 years of the Department of Orthopedics, Philippine General Hospital. The purpose of the present study was to determine the levels of evidence in the researches done by orthopedic residents in training from January 1983 to December 2010. METHODS: The authors reviewed all completed research performed by the department's orthopedic residents in training from January 1983 to December 31, 2010. The exclusion criteria for the study were as follows: review articles, research articles whose full texts were not available and those research articles in which consultants were primary authors. The research articles were scored according to the level of evidence proposed by the Journal of Bone and Joint Surgery (American Volume), and were categorized according to decade: 1980s, 1990s, and 2000s.  RESULTS: A total of 24 research articles were retrieved and reviewed. There were no Level I studies performed in the department by the residents since 1983. There was a significant increase in the number of Level II and Level III studies from the 1980s to the 2000s (p=0.0001). The Hand Section had the highest number of Level II studies 8.6% (3 out of 35) while the Adult Section had the highest number of Level III studies at 21% (11 out of 53). The Pediatric Section had the highest number of Level IV studies at 91% (30 out of 33). CONCLUSION: The level of evidence in research conducted by the orthopedic residents in training of the Department of Orthopedics, Philippine General Hospital has improved significantly in the past 27 years.

Fascial versus fascio-cutaneous pedicled sural flaps in the reconstruction of distal leg, ankle and foot soft tissue defects

BACKGROUND: The coverage of soft tissue defects of the distal leg, ankle or foot poses several challenges to the reconstructive surgeon. Reconstructive procedures may range from simple skin grafting to complicated free tissue transfers. The reverse sural flap has been one of the most dependable methods for soft tissue coverage of such complex wounds. The purpose of this paper was to compare the clinical results of reverse sural flaps harvested with a fascial versus a fasciocutaneous pedicle. METHODS: A retrospective cohort of twenty-six patients who underwent a reverse sural flap procedure for complex wounds of the distal lower extremity was examined from January 1, 2003 to December 31, 2009, with a minimum follow-up of one month. Fifteen patients had a fascial pedicled flap, while eleven patients had fasciocutaneous pedicled flaps with a minimum of one month follow-up. The primary outcome was flap-related complications. Fisher's exact test was used to determine the differences between the two groups and the level of significance was set at p?0.05. RESULTS: All flaps survived. Flap-related complications were more common in the fascial pedicled flap (6/15) compared with the fasciocutaneous pedicled flap (1/11). The difference was not significant (p=0.09). In terms of cosmetic acceptability, 11 patients (11/15) in the fascial pedicle group and five patients (5/11) in the fasciocutaneous pedicle group expressed that the sural flap was acceptable. CONCLUSION: Reverse sural flap was a reliable reconstructive procedure for coverage of soft tissue defects of the distal leg, ankle or foot. There was no significant difference in terms of complication rates for those with fascial compared with those with fasciocutaneous flaps. Cosmetic acceptability was higher for the fascial pedicled flap.

Non-microsurgical technique of fingertip replantation: A report of three cases

The goal of surgery in fingertip amputation is to restore finger length, preserve function and at the same time provide cosmetic acceptability. Treatment options are varied and can range from simple suturing of the stump to microvascular replantation surgery. We report three cases of fingertip amputations in one adult and two pediatric patients treated with non-microsurgical replantation of the fingertip using the palmar "pocket" technique.

Vascularized proximal fibular epiphyseal transfer for shoulder reconstruction after tumor resection

We present a case of an 8-year-old girl with a high grade osteogenic sarcoma of the proximal humerus treated with wide resection and vascularized proximal humerus treated with wide resection and vascularized proximal fibular epiphyseal transfer. At 5 years after reconstruction, the patient is tumor free and had a Musculoskeletal Tumor Score of 26/30 or 86.7%. The functional outcomes in terms of shoulder range of motion and pain were good. Complications include transient peroneal nerve palsy and mild valgus instability of the knee.

Distal radius fractures: Relationship between radiologic parameters and functional outcome

INTRODUCTION: The advent of pedicle screws which provide distraction and derotation has led to higher correction of major curves. Newer methods have been devised to evaluate preoperative coronal flexibility, including lateral-bending (LB), push-prone (PP) and fulcrum-bending (FB) radiographs. Documentation of a consistent radiographic method predictive of correction rate has not been established. OBJECTIVE: To determine the most predictive radiographic method for evaluating spine flexibility and correction by comparing the correction rate (CR), flexibility rate (FR) and correction index (CI) of the Cobb's angle using the different radiographic methods. METHODS: Preoperative radiographs of 20 patients who underwent spinal fusion for adolescent scoliosis were obtained using the LB, PP, and FB method and compared with postoperative radiographs. RESULTS: Comparing the mean Cobb angles using the different methods to that of postoperative standing showed that only the FB method is not significantly different from the latter (p=0.669). There was significant difference between the Cobb's angle measured on the LB and PP and that measured on postoperative standing (p=0.043, p=0.008). Comparing the mean flexibility of the different methods with the mean CR also showed that the mean FR of LB (p=0.007) and PP (p=0.00013) were significantly different from the CR while that of FB is not significantly different from the CR (p=0.687). CONCLUSION: The FB radiograph demonstrated no statistical difference compared to postoperative radiograph, FR and CI.

Result of microsurgical replantation and revascularization surgery of the hand and wrist

Objectives: The objective of this paper was to present the results of replantation and revascularization surgery of the hand or digit and to describe the factors associated with survival of the replanted and revascularized digit. Methods: From January 1, 2005 to July 31, 2010, a retrospective review of the Microsurgery Unit Database was done to determine the number of patients referred to the Unit for amputations of the upper extremity. The injuries were classified by mechanism of injury (guillotine, crush, avulsion, and gunshot/blast), level of injury, and whether or not a vein graft was used. A total of 8 patients with 8 hand parts had replantation surgery and seven patients with 10 revascularized parts were reviewed. Functional Outcome: Functional outcome was measured using the range of motion of the involved digit or body part using a finger or standard goniometer. Sensory recovery of the replanted or revascularized part was measured using the static 2-point discrimination test. Results: A total of 86 patients from January 2005 to July 2010 suffered amputation or near amputation injuries that were referred to the Microsurgery Unit. Of these patients, 8 patients with 8 hand parts had replantation surgeries while 7 patients with 10 hand parts had revascularization surgeries. In total, there were 15 patients (14 males and 1 female) with an average age of 26.2 years old (range, 4-68 years old). The overall viability rate was 72.2% (62.5% for replantation surgery and 80% for revascularization surgery). The average follow-up of the patients who had a successful replantation procedure was 19 months (range, 3-48 months). Those who had successful revascularization procedures after partial or near amputation of the hand or fingers had an average of 7.3 months follow-up (range, 3-14 months). Functional Outcome: Four of the 12 patients had no functional results because of no recovery yet was expected on recent follow-up. In all digital replantations, stiffness was present even after 6 months post replantation. Of the 5 patients who had successful replantation surgery, only 4 had functional results. The best results were from the through wrist and through-palm amputations. Protective sensation was achieved in all tested patients. Conclusion: Successful replantation and revascularization surgery mainly depend on the mechanism of injury. Crush injuries tend to have poorer prognosis compared to guillotine type injuries. Replantation and revascularization surgeries require intensive post-operative rehabilitation to maximize the functional outcome. Key words: replantation, revascularization

Recipient arterial sites of the upper extremity for microsurgical tissue transplantation: a cadaveric study and presentation of clinical cases

Objective: The objective of this study was to define and describe the anatomy of possible recipient arteries in the upper extremity that can be used for free tissue transplantation in a cadaveric model and to present clinical cases making use of these identified vessels. Methods: An anatomic study was carried out to define the possible recipient arteries in the upper extremity that can be used for free tissue transplantation on embalmed cadavers were dissected from the shoulder up to the wrist. The upper extremity was divided into two zones: Zone I was from the coracoid to the medial epicondyle of the humerus and Zone II was from the medial epicondyle up to the radial styloid of the wrist. Three clinical cases for Zone I and two clinical cases for Zone II are presented. Results: At least seven recipient arterial sites in Zone I and five recipient arterial sites in Zone II were suitable for microvascular anastomosis in cases of composite tissue transplantation in the upper extremity. In Zone I recipient sites, the thoraco-dorsal and posterior humeral circumflex arteries have the largest external diameter of around 4.3mm. The smallest external diameter was found to be the superior ulnar collateral artery at 2.0mm. In Zone II, the largest external diameter was found in the radial and ulnar arteries with an average diameter of 3.9mm. The smallest external diameter was the anterior interosseous artery at only 2mm. Conclusion: The upper extremity has many suitable recipient arterial sites for composite tissue transplantation. The knowledge regarding the location, vessel diameter and length will enable the microsurgeon to plan out the reconstructive procedure and know alternative recipient arterial sites when doing composite tissue transplantation of the upper extremity. Key words: recipient artery, composite tissue transplantation, upper extremity flaps

The gluteal fasciocutaneous rotation-advancement flap for sacral decubitus ulcers

OBJECTIVE: This review aimed to present the experience of the Micro-surgery Unit of the Department of Orthopedics of the UP-PGH, in the use of fasciocutaneous rotation-advancement flap coverage for sacral decubitus ulcers.METHODS: A review of patient referred to the unit of management of sacral decubitus ulcers, from 2003-2009. All patients with grades III or IV ulcers, managed with fasciocutaneous flap coverage, and with a minimum follow-up of 1 month were included in the study. Demographic data for all patients were retrieved including albumin level at the time of surgery, operative time, blood loss, complication and status of flap.RESULTS: Twenty-five patients were included in the analysis. The mean age of the patients was 57 years (with a range of 18-78 years). The average operative time was 2.7 hours±1.1 hours and the average blood loss was 428 ml (range, 100 - 500 ml). With a mean follow-up of 9.6 months, there were 3 recurrences and 2 mortalities. Twelve complications were documented in the 25 patients. Seventy-two percent (18/25) had healed sacral flaps on final follow-up.

Anatomic study of the biceps and brachialis branch of the musculocutaneous nerve for brachial plexus reconstruction

OBJECTIVES: The primary objective of this study was to define the anatomy of the musculocutaneous nerve as it innervates the biceps and brachialis muscles in relation to nerve transfer surgery in brachial plexus injury.METHODS: Surgical dissection of the musculocutaneous nerve of both upper extremities of 34 embalmed cadavers was performed to define the anatomy of the musculocutaneous nerve as it supplies the biceps and the brachial muscles. Among the data that we noted were the distance where the branch of the biceps and branchialis took off from the musculocutaneous nerve from the coracoids, which was the bony landmark.RESULTS: There were 17 males and 17 females with a total of 65 musculocutaneous nerve to biceps muscle had an average distance of 10.9cm and a median of 11.0cm±1.83cm (range, 6.5-14.2 cm) from the coracoid. The branching of musculocutaneous nerve to the brachialis had an average distance of 15.1 cm and a median 15.5cm±1.72cm (range, 12.7-21.0cm) from the coracoid. Transferring the fascicles of the ulnar nerve to the biceps branch and a fascicle of the median nerve to the brachialis branch is fairly easy since both nerves are within the vicinity of respective recipient site.CONCLUSION: The anatomy of the musculocutaneous nerve as it supplies the elbow flexors is fairly consistent and there is little discrepancy between cadaveric specimens.