The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest.

BACKGROUND: The feasibility of harvesting a vascularized iliac crest utilizing the Pararectus approach was assessed in cadavers and then this new technique was implemented in a clinical case. METHODS: Bilaterally in five cadavers the branches of both external iliac arteries were injected with colored silicone to assess their position to each other and to harvest a bone graft vascularized by the deep circumflex iliac artery (DCIA) through the Pararectus approach. This technique was implemented in a 68-years-old female patient, initially admitted to a level-I-trauma center after sustaining multiple injuries by falling from great height. For definitive treatment of a severely contaminated medially open (Gustilo-Anderson Type 3A) calcaneal luxation fracture (Sanders type IIIBC) in this patient a vascularized iliac crest autograft harvest by the Pararectus approach was used for reconstructive surgery. RESULTS: The DCIA and the deep inferior epigastric vessels (DIEV: vascularizing the rectus abdominis muscle and main pedicle of the inferiorly based rectus abdominis myocutaneous flap) are very close on the lateral and medial border of the external iliac artery, respectively. As a consequence, the retrograde dissection of the DIEV towards the DCIA through the Pararectus approach made the dissection of the vascularized iliac crest more amenable, preserving both the lateral femoral cutaneous and the genitofemoral nerves. Four months after the surgery the patient was able to fully weight-bear in orthopedic shoes. Radiographs and CT scans showed correct hind foot alignment and bony integration of the vascularized iliac crest graft into the residual calcaneal body. CONCLUSION: The Pararectus approach allowed for secure collection of large vascularized iliac grafts. The presented technique was successful as a salvage procedure in a clinical case with substantial bone loss after an open calcaneal fracture.

Free vascularised osteocutaneous filet flap for covering, that permitted sensitive terminal weight-bearing by a thigh stump after transfemoral amputation.

We covered a transfemoral amputation stump with a modified free filet flap including the calcaneus. The flap survived, resulting in lengthening of the femur, improved distal weight-bearing, preserved sensitivity of the stump, and the design of a prosthesis with terminal loading of the femur rather than an ischial contained prosthesis.

Dynamic force-sharing in multi-digit task.

BACKGROUND: Dynamic hand grasping implies sophisticated motor coordination. Most knowledge on motor synergies used in grasping is deduced from experiments based on static precision grip. This experiment was aimed at better understanding the mechanisms of finger force-sharing in an active, dynamic hand task under repetitive strain conditions. METHODS: A multi-digit task consisting of holding a cylinder with the digit tips, in which the thumb and the finger opposed each other, was investigated during repetitive unidirectional wrist flexion and extension cyclic motion. Finger and thumb forces and wrist angular position were simultaneously recorded during repetitive wrist motion against 0.3-0.6 Nm load in 10 healthy adults. FINDINGS: Load torques acting during wrist movements produced in-phase increases of the thumb and the finger forces with the wrist extension and the wrist flexion, respectively. Digit forces increased proportionally to the applied load. The alternating rise of thumb and finger forces changed instantaneously at the end of the flexion and extension phases of the movement, respectively. Six subjects predominantly used the index finger, two the middle finger, one the ring finger, and the remaining one used the small finger during wrist flexion against 0.6 Nm to perform the task. Variations among individual finger forces were negatively correlated during the phase of constant rotational velocity of the wrist flexion. Repeated measures ANOVA revealed that the percentage of individual finger contribution to the total fingers' force significantly varied during the wrist flexion (P<0.0001) and among wrist flexion cycles (P<0.0001) in each subject. INTERPRETATION: Variations in finger force-sharing among cycles were not necessitated by task dependent activities, as the task was identical. These findings indicated that motor coordination of repeated multi-finger task allowed redundant solutions in finger force-sharing. The force-sharing variation may reflect a minimal intervention principle of the central nervous system controlling only the goal-directed parameters and might help to prevent muscle fatigue in repetitive tasks through modulation of activity in multi-digit muscles.

[Static anterior glenohumeral subluxation following coracoid bone block in combination with pectoralis major transfer: a case report and biomechanical considerations]. / Subluxation antérieure statique de l'épaule après butée pré-glénoïdienne et transfert du grand pectoral. A propos d'un cas et considérations biomécaniques.

We report the case of a patient who experienced post-traumatic static anterosuperior subluxation of the shoulder. The displacement worsened after surgical treatment associating a preglenoid bone block and pectoralis major transfer. We studied the lines of action of the conjoint tendon on an anatomic model. The biomechanical study demonstrated that alone, the coracoid bone block did not provoke the anterior glenohumeral subluxation. On the contrary, the compression components of the humeral head into the glenoid cavity increased and could not explain the worsening dislocation. Inversely, the tendon of the pectoralis major passed in front of the conjoint tendon because of the absence of the subscapularis and could have been the cause of the aggravated anterior subluxation.

The effect of rotational malunion of the radius and the ulna on supination and pronation.

We have assessed the influence of isolated and combined rotational malunion of the radius and ulna on the rotation of the forearm. Osteotomies were made in both the radius and the ulna at the mid-diaphyseal level of five cadaver forearms and stabilised with intramedullary metal implants. Malunion about the axis of the respective forearm bone was produced at intervals of 10 degrees. The ranges of pronation and supination were recorded by a potentiometer under computer control. We examined rotational malunions of 10 degrees to 80 degrees of either the radius or ulna alone and combined rotational malunions of 20 degrees to 60 degrees of both the radius and ulna. Malunion of the ulna in supination had little effect on rotation of the forearm. Malunion of either the radius or of the ulna in pronation gave a moderate reduction of rotation of the forearm. By contrast, malunion of the radius in supination markedly reduced rotation of the forearm, especially with malunion greater than 60 degrees. Combined rotational malunion produced contrasting results. A combination of rotational malunion of the radius and ulna in the same direction had an effect similar to that of an isolated malunion of the radius. A combination in the opposite direction gave the largest limitation of the range of movement. Clinically, rotational malunion may be isolated or part of a complex angular/rotational deformity and rotational malunion may lead to marked impairment of rotation of the forearm. A reproducible method for assessing rotational malunion is therefore needed.

[Reliability of active range-of-motion measurement of the rotation in the forearm: comparison of three measurement devices]. / Reproduzierbarkeit der Messung der aktiven Unterarmdrehung: Vergleich von 3 Methoden.

AIM: The aim of this study is to prove the intra- and interobserver reliability of three different methods to measure the active range-of-motion in the forearm. METHODS: These three different methods were tested on forty volunteers. In the first method pictures were made in full supination and pronation, measurement of the two angles was performed with a dedicated software. Active range-of-motion was defined as the magnitude of forearm rotation between maximum pronation and supination. The second method used a standard goniometer. The third method of assessment used a gravity goniometer (plurimeter). We randomised both the side of the patient to be examined and the sequence of the methods. Two examiners measured subsequently the range-of-motion twice with these three devices. RESULTS: We found a significant intraobserver reproducibility with the gravity goniometer. There was no significance with the goniometer or pictures. The intraobserver reproducibility of the latter two methods was poor. The interobserver reproducibility of the gravity goniometer and pictures was significant, for the goniometer it was poor. Agreement between the pictures and gravity goniometer assessment of the range-of-motion was good. None of these two methods was significantly correlated with the goniometer assessment. CONCLUSION: For reproducibility of measurement of range-of-motion in the forearm the gravity goniometer is the best method, although the measured values were 5 % greater.

Function of the upper limb after surgery for obstetric brachial plexus palsy.

We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by muscle transfer to the shoulder or elbow, and 16 by tendon transfer to the hand. The mean postoperative follow-up was 4 years 8 months. Ten of the 13 children (70%) with an upper palsy regained useful shoulder function and 11 (75%) useful elbow function. Of the 20 children with a total palsy, four (20%) regained useful shoulder function and seven (35%) useful elbow function. Most patients with a total palsy had satisfactory sensation of the hand, but only those with some preoperative hand movement regained satisfactory grasp. The ability to incorporate the palsied arm and hand into a co-ordinated movement pattern correlated with the sensation and prehension of the hand, but not with shoulder and elbow function.

The emotional impact of injury following an international terrorist incident.

BACKGROUND: Terrorism represents a major public health threat throughout the world. Bombings of the United States Embassies in East Africa in 1998 resulted in extensive physical and emotional casualties. METHODS: This study examined posttraumatic stress reactions, worry, and feelings of safety in the workplace in the context of injury in a convenience sample of 21 individuals directly exposed to the bombing in Dar es Salaam, Tanzania. Eight months postbombing, participants completed a self-report instrument examining demographics, exposure, injury, initial reaction, posttraumatic stress, worry, and feelings of safety in the workplace. Descriptive statistics and multiple regression were used to analyze the data. The "Impact of Event Scale-Revised" measured current posttraumatic stress. RESULTS: Report of injury predicted posttraumatic stress, intrusion, and arousal but not avoidance/numbing. Injury and intrusion were significant predictors of ongoing worry. CONCLUSIONS: Even relatively minor injury may be associated with ongoing posttraumatic stress and worry. The participants in the sample were all highly exposed which, along with the small sample size, may have limited the ability to establish other expected relationships.

A composite medial plantar flap for the repair of an achilles' tendon defect: a case report.

The surgical management of infected necrosis of the Achilles' tendon and overlying skin is very demanding, and reconstruction with vascularized tendon and skin flaps is considered the benchmark procedure. The authors report a 65-year-old man who sustained a chronic wound after operative repair of a chronic rupture of the Achilles' tendon. A pedicled medial plantar flap including the surrounding vascularized plantar aponeurosis was elevated. The plantar aponeurosis was split and used to bridge the 4-cm-long tendon defect. The flap donor site was covered with a thin skin graft. The flap survived completely without recurrence of the infection. At the 7-month follow-up, the reconstructed Achilles' tendon showed a good functional result and a normal range of dorsi- and plantar flexion of the foot. This technique is of great interest in comparison with free flaps because it does not require vascular anastomosis in a septic environment or a secondary debulking operation, yet it still provides both vascularized tendon and skin graft.

Idiopathic tumoral calcinosis of the index finger. Case report.

Tumoral calcinosis of the hand is rare, and we present a case report of idiopathic tumoral calcinosis of the index finger, which posed a diagnostic problem as it looked like an infection. We successfully removed the calcific deposit and there had been no recurrence one year after the operation.

A reverse triangular soleus flap based on small distal communicating arterial branches.

We report a 25-year-old woman who suffered traumatic damage to the medial malleolar area. Arteriography revealed a posterior tibial artery occlusion at the ankle. The predominant pattern of medial soleus vascularization was revealed during surgery. A reverse medial soleus flap including the posterior tibial pedicle was elevated. The lateral soleus was gradually elevated with it to ensure a full soleus base of the flap, resulting in a triangular shape. The flap survived completely. Both the triangular shape and the inclusion of the posterior tibial artery pedicle contributed the success of the flap by improving both the arterial supply and the venous drainage along the entire muscular flap.

[Proximal median and ulnar resections. Results of primary and secondary repairs]. / Les sections proximales des nerfs médian et ulnaire. Résultats des réparations primitives et secondaires.

PURPOSE OF THE STUDY: Recovery after median and ulnar nerve proximal repair is widely appreciated. The place and time for secondary functional reconstruction remains controversial. MATERIAL AND METHOD: From January 1983 to January 1990, 66 patients suffering from proximal injury of the median or ulnar nerves underwent nerve repair. Forty-five patients had a postoperative follow-up of more than 24 months: 24 isolated ulnar nerve lesions, 12 isolated median nerve lesions, and 9 combined median and ulnar nerve lesions. Ten patients were given a primary microsurgical nerve suture in our department. Thirty-eight patients underwent a delayed or secondary nerve repair of one or both nerves: 8 secondary nerve sutures, and 35 nerve grafts in 31 patients. RESULTS: Muscular strength, sensitivity, motion, and pain were better after primary nerve sutures (when technically possible) or after shortly delayed secondary sutures, although 40 per cent of patients treated with nerve grafts get final "good" or "very good" results. The time between the injury and nerve repair was the most significant prognosis factor. Results of ulnar nerve repairs at the elbow were statistically better with anterior transposition as compared to in situ repairs (p < 0.005). Fourteen patients required secondary functional reconstruction. Tendon transfers were performed at least 24 months after nerve repair. DISCUSSION: Nerve repair of proximal lesion to the median or ulnar nerves depends on the type of injury, but is advised even when delayed. Residual deficit following nerve repair should require functional transfers depending on hand sensitivity and extrinsic function.

Enhancement of axon growth by detergent-extracted nerve grafts.

BACKGROUND: The immunogenicity of nerve allografts is responsible for their rejection. We have developed a method for preparing cell-free nerve grafts using lysophosphatidylcholine to remove cells, axons, and myelin sheaths. METHODS: The remaining intact nerve extracellular matrix is the extracted nerve graft (eNG). Cultured neonatal Schwann cells were micro-injected into the eNG to form recellularized nerve grafts (rNG). eNG, rNG, and normal isografts (15 mm long) were implanted in the peroneal nerves of F-344 rats. Ten rats were given an eNG on the right, and an isograft on the left. Ten rats were given an rNG on the right, and a sham operation on the left. Sham operation was used as the control and the isograft was used as the benchmark procedure. Walking track analysis was performed every 15 days after surgery to determine the peroneal functional index. Morphometric analysis of the distal peroneal nerve and extensor digitorum muscle weight were analyzed 3 months after surgery. RESULTS: The three types of grafted legs had the classical effect observed after peripheral nerve repair, with decreased functional ability, decreased target muscle weight, fewer large nerve fibers, and more small nerve fibers. Isografts, eNG, and rNG all had similar patterns of peroneal functional index improvement after implantation. The extensor digitorum longus muscle weight and axon counts for the three types of graft were not statistically different. Hence, eNG and rNG can enhance nerve regeneration in the same way as isografts. The host Schwann cells that invaded the implanted eNG probably acted in the same fashion as the cultured Schwann cells injected into the rNG and the resident cells of isografts. CONCLUSIONS: The great permeability of the longitudinally oriented matrix of eNG to cells is, therefore, a major advantage over the reported poor permeability of freeze-thawed nerve grafts.

Lumbosacral agenesis. Three cases of reconstruction using Cotrel-Dubousset or L-rod instrumentation.

Three patients with lumbosacral agenesis underwent surgery to lock the lumbopelvic instability. All three patients had an unstable sitting position and a kyphotic bearing that impaired intestinal transit or hampered further colostomy or ureterostomy. Luque instrumentation with iliac fixation performed according to Galveston was used in one patient. Cotrel-Dubousset instrumentation was used for the two other patients. Autografts plus allografts provided sufficient bone for fusion without requiring lower leg amputations. Increased hip flexion was obtained after pelvic stabilization, but knee flexion contracture remained the same. All patients showed improved intestinal transit or decreased urinary infections, and two patients attained a stable sitting position without aid.

Effects of glutaraldehyde on experimental arterial iso- and allografts in rats.

The effects of glutaraldehyde pretreatment and allograft rejection in arterial grafts were assessed, using iso- and allografts in rats. An in situ glutaraldehyde fixation procedure was used to obtain homogeneous cross-linked vascular biografts. Ten Lewis rats were isografted, ten were isografted with a glutaraldehyde-treated aortic segment, ten were allografted with aortic segments from brown Norway (BN) inbred rats, and ten were allografted with glutaraldehyde-treated BN aortas. The macroscopic and microscopic appearances of the grafts were analyzed 3 weeks after the initial surgery. Immunological injury to the media and the intimal response were quantified morphometrically after monochromatic staining of cell nuclei (hematoxylin after periodic acid), elastin (orcein), and calcification (Von Kossa). Untreated isografts were normal. Untreated allografts showed the classical signs of arterial wall rejection: adventitial inflammatory granuloma, reduced medial thickness and smooth muscle cell density, and greatly increased intimal thickness (P < 0.005). Glutaraldehyde treatment significantly decreased the medial thickness in both iso- and allografts (P < 0.001) and prevented the intimal proliferative response (P < 0.005), but did not change adventitial inflammation. It also induced massive calcification mainly in isografts (P < 0.001). Histomorphological modifications of glutaraldehyde-treated grafts are consistent with a partial protective effect of glutaraldehyde against the rejection process, but also with an induction of a nonspecific inflammatory reaction. Glutaraldehyde-induced cross-linking of the extracellular matrix was responsible for ectopic calcification of the arterial grafts which was independent of the rejection process.