The effects of 5-fluorouracil on flexor tendon healing by using a biodegradable gelatin, slow releasing system: experimental study in a hen model.

This study investigated the effects of 5-fluorouracil in a slow-release biodegradable gelatin system on tendon healing. Gelatin blocks prepared in a size of 10 × 20 × 1 mm were loaded with 10, 20, and 30 mg of 5-fluorouracil, and 30 adult white Leghorn chickens were used. The tendons to the third and fourth toes were severed and repaired. The extremities were casted for three weeks. After sacrifice, the tendons were examined histologically and biomechanically for adhesion formation. The 10 mg-loaded gelatin group showed a decrease in adhesion formation when compared with the operative control group; the 20 and 30 mg groups showed signs of severe inflammation. Low doses of 5-fluorouracil applied via a slow-release gelatin system reduced adhesion formation in flexor tendon healing.

Which instrument should we use to assess hand function after digital replantation?

The functional recovery of a replanted body part is as important as its viability. We compared four instruments frequently used for the evaluation of hand function after digital replantation. The functional results of 17 patients at least one year after replantation of a total digital amputation between 2004 and 2007 were evaluated according to the Tamai, Ipsen, Chen and Disabilities of the Arm, Shoulder and Hand questionnaires. Scores of each patient for each test were calculated and intra-individual comparisons were made. Correlation was significant at the 0.05 level (two tailed) for all tests. A high correlation (>0.71) was found between the Ipsen, Tamai and DASH tests. The Chen test had a moderate correlation with the other tests. We determined that Ipsen, Tamai and DASH tests have similar effectiveness in assessing hand function after replantation.

An Unusual Variation of Deltoid Muscle

An unusual anatomic variation of the deltoid muscle was found in a 45-year-old female cadaver during dissection of the right upper extremity. The posterior fibers of the right deltoid muscle were enclosed in a distinct fascial sheet and the deltoid muscle was seen to arise from the middle 1/3 of the medial border of the scapula. There was no accompanying vascular or neural anomaly of the deltoid muscle. To the best of our knowledge; unilateral posterior separation of the deltoid muscle with a distinct fascia has not been described previously. While dissecting deltoid; posterior deltoid; or scapular flaps; the surgeon needs to look out for this variation because it may cause confusion

Coverage of a thumb wound and correction of a first web space contracture using a longitudinally split reverse radial forearm flap.

The authors describe a new design for a reverse-flow radial forearm flap. A total thumb amputation by severe avulsion was salvaged by microsurgical replantation and a reverse-flow radial forearm flap with a modified design to allow repair of two separate hand defects concomitantly. This newly described flap design for the reverse radial forearm flap offers a refined technique for simultaneous reconstruction of multiple defects in the hand.

Long-term effects of extraluminal dilatation with a rigid circle on arteriovenous anastomotic line in venous grafts transposed into arterial defects.

Postanastomotic narrowing resulting from subintimal hyperplasia is a well-known phenomenon. In the current study the authors compared a metallic circle and conventional suture technique in anastomoses performed in two ends of external jugular vein grafts interposed in carotid arteries of rabbits. They recorded the patency rates, fluid flow rates, and histological effects of the circle on the anastomotic line and compared them with conventional suture anastomoses. In 16 rabbits (experimental group) a standard suture was used in both ends of the jugular vein graft transposed to the carotid arteries on one side. On the other side, circle anastomoses were performed on both ends of the vein graft. In an additional 8 rabbits (control group), the anterior jugular veins and carotid arteries were dissected on both sides and left. During postoperative week 12, in 8 rabbits of the experimental group, the flow rates of carotid arteries were measured in vitro, and intraluminal silicone casts were prepared. In the remaining 8 experimental rabbits, carotid angiographies were performed and anastomotic segments were harvested for histological examination. Flow rates were also measured in the control group, and artery and vein segments were harvested. The patency rates of the vein grafts with metallic circle anastomoses were 100%, whereas conventional suture patency was 75% at week 12. Flow rates were significantly higher in the metallic circle-anastomosed vein grafts (74 ml per minute vs. 123 ml per minute, mean values; p < 0.05). Histological examination revealed reduced intimal thickness in the metallic circle anastomoses compared with conventional suture anastomoses. Dilatation of the arteriovenous end-to-end anastomotic line by a rigid circle prevents anastomotic narrowing in the long term.

Rehabilitation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques.

OBJECTIVE: Kleinert (active extension, rubber-band passive flexion) and Duran (passive extension, passive flexion) protocols are two basic types of early motion programs for rehabilitation of flexor tendon injuries. Researchers have been working on various modifications or combinations of these two protocols to improve rehabilitation results. The purpose of this study was to analyze the quality of the functional results of flexor tendon repair after a postoperative regimen of early mobilization by use of a combined regimen of modified Kleinert and modified Duran techniques. DESIGN: Thirty-seven patients (74 digits) with repaired flexor tendon injuries were treated. Functional results of the fingers were evaluated by the Buck-Gramcko system and total active motion measurements. RESULTS: The results were excellent in 73% of the fingers, good in 24%, fair in 1.5%, and none was rated poor. CONCLUSION: Our results are comparable with the previous studies that used various postoperative rehabilitation techniques. This postoperative management provides an effective way of achieving satisfactory results. Patient-assisted passive exercises are very safe and more cost effective than therapist-assisted passive exercises.

Fingertip replantation at or distal to the nail base: use of the technique of artery-only anastomosis.

The authors describe the functional and aesthetic results of microsurgical replantation of 21 fingertip amputations at or distal to the nail base-namely, zone I amputations. There were 15 male and 6 female patients, with an average age of 26 years (age range, 1-41 years). Replantations were performed using the anastomosis of the artery-only technique, with neither vein nor nerve repair. Venous drainage was provided by an external bleeding method with a fish-mouth incision in "distal" zone I amputations for approximately 7 days, and by the use of leeches in more "proximal" zone I amputations for 10 to 12 days. Results indicated that the overall survival rate was 76%, with 16 of 21 digits surviving. Sensory evaluation at an average follow-up of 12 months (range, 6-18 months) revealed an average static two-point discrimination of 6.1 mm (range, 2.0-8.0 mm). Considering the unfavorable results and the donor site morbidity of various fingertip reconstructions, a microsurgical fingertip replantation should always be considered except in extremely distal, clean-cut, pediatric cases, in which case a composite graft is a possibility. The results of this series indicate that an amputated fingertip in zone I can be salvaged successfully by microvascular anastomosis of the artery only, with a nonmicrosurgical method of venous drainage. Furthermore, acceptable sensory recovery can be expected without any nerve coaptation.

Microsurgical ear replantation without venous repair: failure of development of venous channels despite patency of arterial anastomosis for 14 days.

The authors describe a case of microvascular ear replantation with repair of the artery only and medicinal leech therapy that survived for 14 days but ultimately failed as a result of the absence of development of venous channels between the replant and the recipient bed. A 35-year-old man presented with complete avulsion of 80% of the right external ear. The auricle was revascularized successfully via transposition of the superficial temporal artery (STA) and end-to-end anastomosis between the STA and an identified arterial branch on the posterior surface of the ear, using the technique of longitudinal wedge resection. No suitable veins could be found, therefore medicinal leech therapy was used for venous drainage as well as for systemic heparinization. Although the replant remained viable, frequency of leeching did not decrease over 2 weeks. On postoperative day 14, despite obvious viability of the replanted ear, leeching was stopped, considering the ongoing blood loss. Unfortunately, the auricle was found to be necrosed totally the following day. In retrospect, the authors think that inadequate debridement of nonvital tissues may have led to the failure of development of venous channels between the replant and the recipient bed, as manifested by the frequent requirement of leeching to relieve venous congestion long after revascularization. They conclude that the importance of thorough debridement cannot be overemphasized in microsurgical ear replantation with no vein anastomosis, as demonstrated in their patient. From the point of view of creation of venous drainage channels, deepithelialization of the posterior ear skin may be beneficial.

End-to-side neurorrhaphies of the ulnar and median nerves at the wrist: report of two cases without sensory or motor improvement.

The authors present two unsuccessful clinical cases of end-to-side neurorrhaphy. In the first patient the distal median nerve was coapted in an end-to-side manner to the intact ulnar nerve. In the other patient four cables of sural nerve graft were used to bridge the ulnar nerve and the intact median nerve by two end-to-side coaptations. Neurorrhaphies were performed via epineural sutures through epineural windows. Both of the cases failed to demonstrate any signs of regeneration either clinically or as evidenced by electromyography, Semmes-Weinstein monofilament test, or 256-Hz vibration tests at 18 and 21 months' follow-up respectively.

Two new intramedullary implant designs for phalanx fixation in digital replantation: an experimental study.

Bone fixation in digital replantation must provide adequate rigidity, and must be applied in a fast and easy manner. Various fixation methods have been used so far with certain advantages and disadvantages. The authors report two new intramedullary proximal phalangeal implant designs to secure two amputated bone segments tightly. They compare their intramedullary implants with commonly applied K-wire fixation methods and plate fixation via biomechanical analysis in terms of bending rigidity and distraction strength. Their two-sided asymmetrical screw provided the highest rigidity and distraction strength, whereas the hook-trap system was nearly equal to cross-K-wire fixation. Intramedullary bone fixation may be a feasible method of bone fixation, and resorbable implant materials and different implant configurations deserve further investigation.

A rat musculocutaneous flap model: the biceps femoris musculocutaneous flap.

The purpose of this study was to describe a new musculocutaneous flap model in the rat. A total of 25 Wistar rats weighing 200 to 280 g were used in this experiment. In 15 rats, the vascular anatomy of the biceps femoris muscle and the cutaneous blood supply of its overlying posterior thigh skin were studied by anatomic dissection, dye injection, and microangiography using 5 rats in each group. The anatomic studies revealed that the main axial vessel supplying the biceps femoris muscle was the caudal femoral branch of the popliteal vessels. The posterior thigh skin overlying the biceps femoris muscle received a consistent musculocutaneous perforator at the center of the mid-posterior line of the posterior thigh. Based on the caudal femoral-popliteal vascular pedicle, the biceps femoris musculocutaneous flap was created in the rat, comprised of the whole muscle and its overlying posterior thigh skin. The skin paddle was designed as an ellipse with its longitudinal axis paralleling that of the extremity, generally measuring 4 x 2 cm. Island flaps were raised as described and replaced either in situ (N = 5) or transposed to a sacral defect (N = 5). Results showed that the cutaneous islands of all the flaps survived completely. Tetrazolium blue stain used to indicate muscle survival revealed that the average muscle viability was 86.7+/-3.4%. The authors conclude that the biceps femoris musculocutaneous flap is a reliable and true musculocutaneous flap model for future biological and pharmacological studies. It offers the following advantages: It has a consistent vascular pedicle and a musculocutaneous perforator, it supports a relatively large skin island, and there is no risk of autocannibalization of the flap because the flap is located dorsally.

Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation.

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.