One-stage elbow interposition arthroplasty with a fasciocutaneous distally planned lateral arm flap.

We report a case of severe posttraumatic ankylosis of the elbow with chronic osteomyelitis of the lateral condyle of the humerus. The triple problem of restoring elbow mobility, providing for coverage, and controlling infection was treated in a one-stage procedure. A distally planned fasciocutaneous lateral arm flap was used for elbow interposition arthroplasty. Clinical examination at 27 months showed restoration of a useful range of elbow motion and good pain relief.

Dorsal carpometarcarpal dislocation of ulnar fingers. A case report.

Multiple dorsal dislocations of the carpometacarpal joints are rare. Diagnosis requires a high index of suspicion, careful examination and good radiography. Treatment is controversial and is based on the presence or not of associated fractures. This paper presents a case of combined fifth and fourth finger carpometacarpal joint dorsal dislocation, successfully treated with closed reduction and percutaneous pinning. A discussion of this pattern of injury is also presented.

The nerve supply of the trapeziometacarpal joint.

Ten forearm and hand specimens from fresh cadavers were dissected and examined under magnification for articular branches to the trapeziometacarpal joint arising from the thenar and palmar cutaneous branches of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm. In all but one specimen the thenar branch of the median nerve sent an articular branch to the trapeziometacarpal joint. Multiple branches from the palmar cutaneous branch of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm were also found. All these branches need to be divided during a "complete" denervation of the trapeziometacarpal joint.

Do multiple consecutive head and neck reconstructions improve the patients functional outcome?

BACKGROUND: The purpose of this study was to determined the functional outcome of surgically treated head and neck cancer patients who required more than "standard" microsurgical reconstruction. METHODS: Data concerning all patients with head and neck cancers, who underwent free-tissue transfers in our institution between January 1, 1994 and August 31, 1999 were reviewed. The cases of tumor recurrences and those with micro-surgical complications were excluded. Among 68 primary microsurgical reconstructions, we identified five cases where limitations in speech and/or swallowing required additional flap procedures. An objective assessment of speech and swallowing could be performed in four patients. RESULTS: In these five patients up to three consecutive additional procedured including three free-tissue transfers in one case, had to be performed mainly because of secondary contraction of the surrounding irradiated tissue. A total of 13 pedicled and free flaps were transferred to the head and neck. Three patients underwent two consecutive free tissue transfers. The additional reconstructions were requested to improved tongue mobility in three patients and to enlarge the upper digestive tract in two patients. The mean follow-up was 23 months (range : 9-53 months). Functional evaluation was rated average in three patients and poor in one patient. One patient died before functional evaluation could be performed because of disease. The four patients judged the final cosmetic result as satisfactory. CONCLUSION: We report five cases of head and neck microsurgical reconstructions where additional flap procedures were requested because of inadequately restored speech or nutrition capabilities. We show that, maybe because of extensive fibrosis, only limited improvement in the functional outcome can be expected despite the use of even sophisticated microsurgical reconstructions. This paper supports the idea that every effort should be put in the initial reconstruction, as further procedures are of poor functional prognosis.

[Thenar branch of the median nerve and innervation of the trapeziometacarpal joint]. / Rameau thénarien du nerf médian et innervation trapézométacarpienne.

INTRODUCTION: Denervation has been proposed successfully for chronic wrist pain. This procedure is not commonly performed for degenerative osteoarthritis of the trapeziometacarpal joint. According to the classic anatomical descriptions of the wrist innervation, it seems that the thenar branch of the median nerve (TBMN) is the only nerve of the wrist for which no articular branches are clearly defined. The aim of this study is to complete the few anatomical descriptions of the trapeziometacarpal joint innervation with microdissections of the TBMN. MATERIALS AND METHODS: Ten wrist and hand specimens from fresh cadavers were dissected by the same operator under magnification (3.5-12x). The TBMN was identified at its origin from the median nerve and followed in the thenar muscles. All the divisions of the TBMN were identified and followed to their terminal branches. RESULTS: The TBMN divided in at least two main branches, one each to the opponens and to the abductor pollicis brevis. In all but one specimen, the branch to the opponens pollicis muscle passed over or into its medial aspect to spread on the palmar side of the trapezium. Each dissected articular branches were histologically confirmed. DISCUSSION: Our results show a clear participation of the TBMN in the innervation of the trapeziometacarpal joint. The lack of knowledge of this anatomical feature may explain the inconstant results obtained with selective denervation of the trapeziometacarpal joint.

Use of gracilis muscle free flap for reconstruction of chronic osteomyelitis of foot and ankle.

Despite low donor-site morbidity and a straightforward dissection, the gracilis muscle flap is still for many surgeons a second choice in microsurgical reconstruction of the lower extremity in cases of osteomyelitis. They underscore the difficulty of the procedure, and the problems of insufficient muscle volume and a small sized vascular pedicle. The aim of this study was to assess the reliability of the gracilis muscle free flap in the treatment of osteomyelitis of the foot and ankle. Between 1992 and 1999, 12 consecutive cases (age 9 to 71 years) of osteomyelitis of the foot and ankle were treated using a skin-grafted gracilis free muscle flap. Criteria for osteomyelitis were the presence of exposed bone, positive cultures and bone scans. The wound defect surface ranged from 9 to 90 cm2 (mean 50.5 cm2). Six flaps were applied on the weight bearing area of the foot. Flap harvesting time never exceeded 30 minutes. The mean follow-up is 15 months (range 2 to 60 months). All flaps survived completely. Secondary skin grafts were needed in two cases. One hematoma was noted at the flap donor site. Two patients (18%) had persistent osteomyelitis due to insufficient debridement in the presence of what appeared to be extensive bone involvement. Attempt to salvage the extremity was first performed but ultimately led to amputation. No patients complained of any donor site morbidity. Failure to cure the osteomyelitis was never caused by inadequate flap coverage. Gracilis muscle flap reliability in terms of vascular supply and ease of dissection made it our first choice in osteomyelitis of the foot and ankle. In the presence of extensive bone involvement, complex bone reconstruction is necessary to avoid amputation.

Congenital syndactyly: defatting facilitates closure without skin graft.

We attempted to correct 24 syndactylies without skin grafts in 16 consecutive patients. Digital volume was decreased by defatting the full length of the fingers and the interdigital space. Closure of the zigzag incisions on both fingers could then be achieved with minimal tension and did not seem to be related to the type of flap used for commissure resurfacing. We used 2 different types of flap closure. We noted that defatting was a more important determinant of whether the wound could be closed without graft than flap configuration. The new type of flap may represent an improvement for web appearance but is not a determination for finger closure. Only a complex syndactyly involving 3 adjacent atrophied fingers required a skin graft for separation. The results were evaluated after a mean follow-up period of 22 months. Three patients had a complication: an intraoperative digital nerve laceration, a scar contracture, and a recurrence of the treated commissure due to local infection. Two patients needed another surgical procedure. Supple and good quality scars were observed in the other patients. No conspicuous change in finger contour compared with the nonsyndactylized fingers was observed.

Evaluation of the donor site morbidity after lateral arm flap with skin paddle extending over the elbow joint.

The free lateral arm flap may be extended to include the skin over the lateral aspect of the elbow and the forearm. However, extending the flap beyond the lateral condyle has been thought to interfere with the elbow function. The aim of this study was to assess the donor site morbidity after placement of the skin paddle across the lateral aspect of the elbow joint. Seventeen consecutive lateral arm flaps with a skin paddle designed over the elbow joint were performed for different indications. Eleven patients were followed up postoperatively for a minimum of 6 months. The range of motion, torque, power and endurance of the elbow joint were recorded using a Cybex 340 isometric dynamometer. The values of the operated elbow were compared to those of the unoperated elbow and the deficits were expressed in percentages. The touch sensation in the territory of the posterior cutaneous nerve of the forearm was assessed using Semmes-Weinstein monofilaments. Patient satisfaction was evaluated with a self-assessment scale. The donor site scar was stretched in one patient. No patient complained of elbow pain or cold intolerance. Elbow mobility was not significantly affected by flap harvesting (P = 0.06). An extension deficit of 4% was found in four patients. The mean torque, power and endurance deficits were 7.3%, 7.5% and 4.4% respectively as compared to the contralateral side. Complete loss of sensation was not present in any of the donor sites. However, an area of hypoaesthesia with a mean size of 45 cm(2)(range 20-75 cm(2)) was found on the posterolateral surface of the forearm. Patient satisfaction with the donor site was rated high. From this retrospective review it appears that elbow function was not significantly affected by extending or planning the lateral arm flap over the lateral condyle.

One-stage reconstruction of an infected skin and Achilles tendon defect with a composite distally planned lateral arm flap.

In this paper, the treatment of a complicated Achilles tendon defect with a composite lateral arm flap with distal design of the skin paddle has been presented. The extended portion of the flap was sufficient to restore adequate contour to the posterior aspect of the ankle, and reinervation showed good protective sensation at 1 year. In terms of resurfacing, the use of the reinervated lateral arm flap with a distal design of the skin paddle seems advantageous. The weakening of the reconstructed Achilles tendon, although without clinical incidence and impairment of elbow extensors at this stage, may indicate that a better substitute than the triceps tendon has to be found. Nevertheless, we would best reconstruct such an Achilles tendon defect by the same technique because of the well vascularized autologous tissue it provides, limiting the risk of infection.

The distally planned lateral arm flap in hand reconstruction.

The lateral arm flap is a versatile free flap with straightforward dissection and low donor site morbidity. However, it presents some drawbacks: the vascular pedicle is relatively short (2-6 cm), and the flap is rather thick. Further surgery is often needed to decrease flap volume. An anastomotic network between the posterior collateral radial artery and the recurrent radial artery allows the skin paddle to be safety located over the epicondylar region and proximal forearm. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of eight consecutive distally planned lateral arm flaps used for hand reconstruction is presented. The medical records and operative notes were reviewed. Six patients were reviewed. The minimum follow-up was six months. Flap size ranged from 11 x 5.5 cm to 23 x 7 cm (average 15 x 6 cm), pedicle length ranged from 8 to 10 cm (average 9 cm), no venous grafts were needed for the microanastomosis. The mean flap harvesting time was 50 minutes. All donor sites were closed primarily. All flaps survived totally despite postoperative arterial thrombosis in one case that was salvaged by a skin graft over the surviving fascia. To date, no further surgery was needed to debulk the flaps. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment of appearance of both reconstruction and donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle than the classical lateral arm flap with no added technical difficulties.

The distally based lateral arm flap for intraoral soft tissue reconstruction.

BACKGROUND: The radial forearm flap is probably the most frequently used among free flaps for intraoral soft tissue reconstruction. However, this flap is not always available. The other fasciocutaneous flaps may be too bulky or less pliable or may have a short vascular pedicle; their use is therefore less than ideal. We present a variant of the lateral arm flap located distally to the lateral epicondyle and having the same advantages as the radial forearm flap. METHODS: Vascular study (dissection and radiography) was previously undertaken to determine the vascular anastomotic network in the epicondylar area, between the posterior radial collateral artery and recurrent arteries running in front of the lateral epicondyle. This demonstrated the possibility of taking a skin paddle on and below the lateral epicondyle, based on the proximal pedicle. RESULTS: We used this flap on three patients for intraoral soft tissue reconstruction (tonsil, floor of the mouth, and piriform sinus). No complication with the flap itself was encountered. In all cases, direct closure of the donor site was possible, with no local complication. CONCLUSION: The distal lateral arm flap (LAF) represents an interesting and reliable alternative to the fasciocutaneous radial forearm flap. The positioning of the skin paddle over the lateral epicondyle and the proximal third of the lateral aspect of the forearm increases pedicle length, thus avoiding the use of vein grafts. Dissection is straightforward with a reliable vascular anatomy. Moreover, in this area, the limited amount of subcutaneous fatty tissue ensures easier placement and more pliability when compared with the standard LAF.

Endothelin-A receptors mediate vascular smooth-muscle response to moderate acidosis in the canine tibial nutrient artery.

Perfusate pH may influence the tone of vascular smooth muscle by affecting the release of endothelium-derived vasoactive factors or by directly modulating function of the smooth muscle. This study was designed to investigate the role of endothelium-derived factors on acidosis-induced responses of isolated canine tibial nutrient artery suspended in an organ chamber for the measurement of isometric contractile force. To investigate the specific role of the endothelium in half the rings, the endothelium was removed mechanically. Concentration-response curves to KCl were obtained in the absence or presence of inhibition of two important endothelium-derived relaxing factors, nitric oxide and prostacyclin, and an inhibitor of receptors for the endothelium-derived contracting factor, endothelin-1. Acidification of the perfusate from pH 7.45 to 7.0 significantly attenuated the contractions to KCl in arterial rings with endothelium (the mean of the effective concentration causing 50% of the maximal response for KCl at pH 7.45 and 7.0 was 12.31 +/- 0.40 nM and 14.60 +/- 0.55 nM, respectively). This difference was abolished by mechanical removal of the endothelium. In rings with endothelium, inhibition of nitric oxide or prostacyclin did not abolish the attenuation of KCl-induced contractions occurring with acidosis (the mean of the effective concentration causing 50% of the maximal response for KCl at pH 7.45 and 7.0 was 11.18 +/- 0.60 nM and 13.60 +/- 0.60 nM, respectively). Inhibition of endothelin-A receptors did not alter contractions to KCl at pH 7.45. However, the acidosis-induced attenuation of contractions with KCl was abolished by the endothelin-A-receptor antagonist BQ-123 (the mean of the effective concentration causing 50% of the maximal response at pH 7.45 and 7.0 was 13.8 +/- 1.34 nM and 13.2 +/- 1.34 nM, respectively). These results suggest that acidosis-induced relaxation of canine tibial nutrient artery is endothelium dependent and that activation of endothelin-A receptors during acidosis is coupled to a release of an endothelium-derived relaxing factor.

Endothelin induces vasoconstriction in the bone vasculature in vitro: an effect mediated by a single receptor population.

The aim of this study was to define the types of endothelin receptors present in the canine tibial vasculature. Endothelin receptor agonists and antagonists were used in two different models: isolated nutrient tibial arteries in organ bath and in vitro-perfused canine tibial bones. In isolated nutrient tibial arteries, endothelin-1 caused concentration-dependent contractions of rings with and without endothelium. BQ-123, a selective endothelin-A antagonist, induced a significant rightward shift of endothelin-1 concentration-response curves. No contractions were observed with sarafotoxin S6c, a selective endothelin-B agonist. The responses of endothelin-1 were not affected by the presence of NG-monomethyl-L-arginine acetate plus indomethacin or by removal of the endothelium. In perfused tibial bones, endothelin-1 was more potent than endothelin-3 in causing concentration-dependent contractions. Neither endothelin-1, endothelin-3, nor sarafotoxin S6c caused relaxations. Neither the inhibition of nitric oxide nor the inhibition of prostaglandins significantly altered contractions to endothelin-1. These concordant data indicate that endothelin is a vasoconstrictor in the bone vasculature, an effect that appears to be mediated only through endothelin-A receptors.

Distally planned lateral arm flap.

The lateral arm flap presents some drawbacks: the vascular pedicle is short (2-6 cm), and the flap is rather thick. An anastomotic network between the posterior radial collateral artery and the recurrent radial artery, demonstrated by our previous anatomical dissections, enables one to locate the skin paddle solely over the epicondylar region and the proximal forearm. Furthermore, since no skin is harvested over the lateral aspect of the arm, a random-type vascularisation for the distal skin can be excluded. This modification increases pedicle length up to 100% and limits the amount of subcutaneous fat. A series of 13 consecutive distally based lateral arm flaps was performed, and eight patients were followed up for a minimum of 12 months postoperatively. Flap size ranged from 8 x 5.5 cm to 23 x 7 cm (average, 14 x 6 cm), and pedicle length ranged from 9 to 14 cm (average, 10.5 cm). No venous grafts were needed. The mean flap harvesting time was 60 minutes. All the donor sites were closed primarily. One flap suffered from an arterial thrombosis and only partially survived, and another healed uneventfully after successful re-exploration of a venous thrombosis. Only one flap had to be partially debulked. The donor site scar was enlarged in one patient. Elbow mobility was unaffected by surgery. Patient self-assessment on the appearance of both the reconstruction and the donor site showed a high satisfaction rate. The distally planned lateral arm flap presents decreased bulk and a longer pedicle when compared with the classical lateral arm flap with no added technical difficulties or morbidity.

Evaluation of influence of 24-hour cold preservation on endothelin production and on endothelin receptors in the bone vasculature.

Endothelin-1 is a vasoactive peptide produced by the vascular endothelium. It is one of the most potent endogenous vascular smooth muscle constrictors. Two subtypes of the endothelin receptor have been cloned and sequenced and denoted endothelin-A and endothelin-B. The aim of this study was to define the influence of cold ischemia on the production of endothelin-1 and on the endothelin receptors. Two different preservation techniques (cold storage only and cold storage with microperfusion with University of Wisconsin solution) also were compared. The study was performed in an in vitro bone perfusion model to isolate the vascular endothelium from blood components. The production of endothelin-1 by the bone vasculature was not altered after 24 hours of cold ischemia. No contractions were observed with S6c, a selective endothelin-B agonist, and this effect was not influenced by cold ischemia. The response mediated by the endothelin-A receptor was increased significantly, an effect that was not influenced by preservation with University of Wisconsin solution. This latter finding was the only significant alteration in the vascular function detected in the in vitro model after 24 hours of cold ischemia. With regard to the pharmacologic properties of endothelin-1, this mediated response could be implicated in the pathogenesis of vasospasm.

Levator scapulae transfer and fascia lata fasciodesis for chronic spinal accessory nerve palsy.

A retrospective evaluation of the functional results after reconstructive treatment with levator scapulae transfer and scapulo-spinal fasciodesis by fascia lata slings for complete chronic trapezius palsy is presented. Five patients (ages 6 to 40 years) were operated on between 1988 and 1991 because of incapacitating pain and/or functional limitations. Treatment was recommended after failure to alleviate symptoms by a shoulder-girdle muscle-strengthening program or after unsuccessful nerve graft. The descriptions of the results are drawn from the last follow-up evaluation available for each patient (minimum: 14 months post-operative). They are expressed in terms of functional recovery, residual pain, and patient satisfaction. Three patients had an excellent result, with at least 80 percent of normal abduction and forward elevation of the arm, no residual pain, and a high satisfaction rate. One patient showed good improvement in function, with 90 percent of normal shoulder function, but complained of some residual pain. The last patient was not improved by the surgery. Levator scapulae transfer and scapulo-spinal fasciodesis by fascia lata slings, substitute for the function of the upper trapezius and enhance the function of the serratus anterior, thus helping to relieve pain and to improve shoulder function after chronic trapezius palsy. The procedure warrants consideration in patients who are not candidates for nerve repair and reconstruction.

Simultaneous bilateral facial reconstruction of a Barraquer-Simons lipodystrophy with free TRAM flaps.

Barraquer-Simons lipodystrophy is a rare disorder of unknown origin characterized by a progressive atrophy of the subcutaneous fat of the upper part of the body. Renal disease with abnormalities of complement factors is the most frequent accompanying feature. A case is presented in which bilateral facial contour has been restored simultaneously with two deepithelialized TRAM flaps.

Endothelin: an endothelium-derived vasoactive peptide.

Endothelin is a 21-amino-acid, vasoactive peptide. Sequence analysis of cloned cDNAs for porcine and human endothelin precursors showed that endothelin-1 (ET-1) is produced in the endothelial cells. The peptide, endothelin (ET), was first identified as a potent vasoconstrictor. It is one of the most potent endogenous vascular smooth-muscle constrictors, ten times more potent than angiotensin II, vasopressin, and neuropeptide Y. Shortly after the discovery of this vasoconstrictor peptide, it was revealed that endothelin also possesses vasodilator properties at doses lower than those necessary to produce vasoconstriction. However, controversy still exists over the mechanism(s) of action; prostacyclin and endothelium-derived relaxing factor (EDRF) have mainly been implicated as the source of the initial vasodepressor effect. ET also elicits markedly different regional hemodynamic response patterns. There is a heterogeneity in the observed vasodilation or vasoconstriction, depending on species and on vascular beds studied in the same species. Endothelin has been implicated in a number of pathologic situations, including tissue ischemia and vasospasm. ET seems to be produced more actively around the site of endothelial damage; the loss of balance between its vasodilator- and vasoconstrictor-induced responses could contribute to its patho-physiologic properties. Experimental results strongly support the concept that ET could be important in controlling vascular tonus, both in the healthy and the diseased vessel.

Free TRAM flap for lower-extremity reconstruction.

The usefulness of TRAM flaps is well-established. Their use in soft-tissue reconstruction of the lower limbs is illustrated. The flaps allow coverage of soft-tissue defects with good quality skin, and add bulk to enhance leg contour. Three cases are presented, and the advantages of this flap are discussed.