Median nerve biodegradable wrapping : Clinical outcome of 10 patients.

Nerve wrap protectors are bioabsorbable synthetic materials made of collagen or extracellular matrix that provide a non-constricting encasement for injured peripheral nerves. They are designed to be used as an interface between the nerve and the surrounding tissue. After hydrated, they transform into a soft, pliable, nonfriable, easy to handle porous conduit. The wall of the nerve wrap has a longitudinal slit that allows to be placed around the injured nerve. Τhis article presents the surgical technique for median nerve neurolysis and nerve coverage using a collagen or an extracellular matrix nerve wrap protector in 10 patients with recurrent or persistent carpal -tunnel syndrome. All patients had a mean of three previous open carpal tunnel operations, which were not successful. The mean follow-up was 3 years. -Under axillary nerve block anaesthesia with the use of -pneumatic tourniquet, a standard open carpal tunnel approach was done incorporating the previous incision. Scar tissue was excised in a healthy bed and the median nerve was thoroughly released with external neurolysis. An appropriate length of nerve wrap protector was cut longitudinally according to the length of nerve release. The nerve wrap was loosely sutured with separate polypropylene sutures No. 7-0. A volar splint was applied for a mean of 2 weeks followed by progressive passive and active range of motion rehabilitation exercises of the wrist and fingers. At the last follow-up, all patients showed improvement of clinical symptoms, static two-point discrimination test and median nerve conduction studies, and absence of Tinel sign. Differences in outcome and complications with respect to the nerve wrap materials used were not observed.

Arthroscopic triangular fibrocartilage complex debridement using radiofrequency probes.

The initial results of using radiofrequency probes for debridement of a torn triangular fibrocartilage complex were studied in 20 patients with a mean age of 44 (range 27-56) years presenting with ulnar-sided wrist pain. On arthroscopic examination, 18 central and two radial triangular fibrocartilage complex tears were identified and debrided to a stable rim using radiofrequency probes. The mean follow-up was 22 (range 9-35) months. Seventeen patients experienced substantial pain relief. In three, the pain was unchanged. The mean flexion extension arc was 132 degrees , pronosupination arc 155 degrees and mean grip strength was 83% of that of the unaffected side. Using the modified Mayo wrist score, there were ten excellent, seven good and three fair results. No perioperative complications occurred. Radiofrequency probes were found to be safe and effective for use in triangular fibrocartilage complex debridement. These results compare favourably with other standard methods of treatment of this problem.

Suture anchor repair of ulnar-sided triangular fibrocartilage complex tears.

Traditional open repair of traumatic triangular fibrocartilage complex (TFCC) tears requires a relatively extensive exposure, and arthroscopic repair, though conceptually simple, can be technically demanding. We describe a mini-open suture anchor technique that, while minimally invasive, is easier to perform than previously described open or arthroscopic techniques. Results achieved using this technique in eight cases compare favourably with those reported for other techniques.

An allograft salvage technique for failure of the Darrach procedure: a report of four cases.

We report on four patients with failed resections of the distal ulna causing instability and impingement, who were treated with a tendon allograft to stabilize and buffer the ulnar stump. In three of the four patients the outcome was excellent. We believe that this new technique holds promise as an alternative salvage procedure for the failed Darrach resection.

Partial rupture of the distal biceps tendon.

We report on 7 cases of partial rupture of the distal biceps tendon. The mean patient age was 52 years (range, 38-58 years). There were 5 men and 2 women. The dominant arm was affected in all 7 patients. Pain was the chief complaint in all patients. Immobilization and physiotherapy were attempted in all patients, and 4 had at least 1 local steroid injection. No patient improved from the conservative treatment. All patients eventually underwent surgical debridement and reattachment of the biceps tendon with use of a 1-incision technique with suture anchors. After a mean follow-up of 31 months (range, 25-44 months), all patients reported a significant decrease in their pain. No complications were noted.

Diagnosis and management of acute fracture-dislocation of the carpus.

Acute fracture-dislocations of the carpus are uncommon. If treated inadequately, however, these injuries can lead to wrist pain and dysfunction as a result of progressive traumatic arthritis. Accurate diagnosis and early intervention are essential for optimal recovery. This article presents the anatomy, epidemiology, and mechanisms of injury of the carpus and the diagnosis, treatment, and treatment results of dislocation of the carpus.

Classification of osteonecrosis of the femoral head. Reliability, reproducibility, and prognostic value.

The purpose of the current investigation was to determine interobserver and intraobserver reliability of the classification system of Steinberg et al for osteonecrosis of the femoral head. Sixty-five anteroposterior and lateral radiographs of hips were selected randomly from a pool of patients with confirmed osteonecrosis of the femoral head. Six fellowship-trained observers viewed the radiographs (Reading 1). The observers used six main stages of the classification excluding A, B, and C subgroups. The same observers viewed the radiographs 4 months later in reverse order (Reading 2). Reading 1 was used to calculate interobserver kappa values. Reading 2 was used to calculate intraobserver kappa values. Stage-specific kappa values for interobserver variation between all viewers were as follows: Stage I, k = 0.64; Stage II, k = 0.51; Stage III, k = 0.21; Stage IV, k = 0.49; Stage V, k = 0.36; and Stage VI, k = 0.80. Stage-specific kappa values for intraobserver variation between all viewers were as follows: Stage I, k = 0.74; Stage II, k = 0.60; Stage III, k = 0.46; Stage IV, k = 0.59; Stage V, k = 0.27; and Stage VI, k = 0.78. An average of 10 of 21 (48%) of these errors involved Stage III. An average of 6.3 of 21 (30%) intraobserver errors involved Stage V. The presence of the crescent sign in Stage III and joint space narrowing in Stage V markedly diminished the overall reliability of any four- to six-stage classification system. Based on the authors' experience and analysis of the current classifications of osteonecrosis of the femoral head, an easy and reproducible Pittsburgh classification system is proposed.

Treatment of recurrent compressive neuropathy of peripheral nerves in the upper extremity with an autologous vein insulator.

The treatment of entrapment neuropathy in the upper extremity with surgical decompression has generally provided good results. Recurrence of symptoms, however, is not uncommon and its management is both challenging and difficult. Nineteen patients with recurrent carpal tunnel and cubital tunnel syndrome were treated with the vein wrapping technique using the autogenous saphenous vein. The average number of surgeries before vein wrapping was 3.3. The mean patient age was 53 years (range, 28-75 years) and the mean follow-up period was 43 months (range, 24-78 months). All patients reported reduction in pain and the sensory disturbances secondary to the compression of the median or ulnar nerve. Two-point discrimination and electrodiagnostic findings also improved.

Vascularized orthotopic osteochondral transplantation of the canine proximal femur.

Osteochondral vascularized proximal femoral allografts were orthotopically transplanted in five adult beagles (four experimental and one control). The experimental animals were placed on 0.1 mg/kg of FK506 intravenously for 7 days, and then converted to 1.0 mg/kg orally. Biopsies of the femoral heads were taken at 3 weeks postoperatively and at 1-month intervals thereafter. The specimens were studied histologically with a hemotoxylin and eosin staining technique. Bone biopsies showed no microscopic evidence of rejection, and only minimal evidence of necrosis. Patency of the microvascular anastomosis was confirmed with bone scanning, using technitium 99m phosphate, arteriograms, and by Doppler flowmeter. All animals had an uneventful postoperative course, with achievement of full weight-bearing status by postoperative day 10, and normal activity by 1 month postoperatively. There were no infections or hip dislocations. One animal sustained a femoral neck fracture and was sacrificed at 4 months. At 6 months, the remaining animals were sacrificed. At necropsy, the experimental animals and the normal dog showed viable chondrocytes and osteocytes, with minimal bone necrosis. No dislocations or allograft rejections were observed. Based on this small series, a successful technique has been developed for orthotopic transplantation of a vascularized hip joint in a canine model.

Growth factor may decrease muscle atrophy secondary to denervation.

Despite modern microsurgical techniques, functional outcomes following brachial-plexus reconstruction and peripheral-nerve repair are usually unsatisfactory, because irreversible muscle atrophy develops before reinnervation occurs. Insulin growth factor-1 (IGF-1) has been shown to improve muscle regeneration after injury, and may have a role in muscle preservation following denervation. This study evaluated the histologic, immunohistochemical, and electrophysiologic differences between normal and denervated muscle over an 8-week time period, and also evaluated the effects of injecting IGF-1 into denervated muscle. Denervated mice gastrocnemius muscles demonstrated a decrease in muscle diameter, a decrease in muscle weight, early nuclear proliferation, and a decrease in fast twitch and maximum tetanic strength, compared to normal gastrocnemius muscle up to 8 weeks following denervation. Four weeks after denervated muscle was injected with IGF-1 at time zero, however, relative preservation of muscle diameter and weight, and maintenance of electrophysiologic contractile properties were observed. These preliminary data suggest that IGF-1 may prevent muscle atrophy secondary to denervation.

Findings of exploration of a vein-wrapped ulnar nerve: report of a case.

A 54-year-old woman underwent a revision procedure after failure of 3 previous procedures for recalcitrant cubital tunnel syndrome. She underwent neurolysis and vein wrapping of the ulnar nerve during the fourth procedure. Two years later she developed a neuroma of the medial antebrachial cutaneous nerve necessitating a fifth procedure. At the time of neuroma relocation we noted that the vein was intact around the ulnar nerve and that there was no scarring between the vein and nerve.

Minimal medial epicondylectomy and decompression for cubital tunnel syndrome.

Sixty-four patients (66 elbows) treated for refractory cubital tunnel syndrome had minimal medial epicondylectomy and in situ decompression to minimize the potential disadvantages of classic medial epicondylectomy. After a mean followup of 27 months results were excellent in 27 patients (44%), good in 23 patients (35%), fair in 10 patients (15%), and poor in four patients (6%). No ulnar nerve palsy, ulnar nerve subluxation, or medial elbow instability were seen. The main complaint of patients regarding the procedure was tenderness at the osteotomy site. The results show that minimal medial epicondylectomy and in situ decompression of the ulnar nerve is a safe and effective method to treat patients with cubital tunnel syndrome. This procedure minimizes the disadvantage of medial instability and recurrent symptoms attributable to nerve trauma after a classic medial epicondylectomy.

The Compass Elbow Hinge: indications and initial results.

The Compass Elbow Hinge uses Illizarov's methods of fixation to externally hold the elbow reduced and allow both passive and active motion. Eleven patients with degenerative disease, contracture or instability were treated with the Compass Elbow Hinge and were retrospectively evaluated at an average follow-up of 29 months (range: 18-62 months). One was lost to follow-up. Patients with degenerative changes underwent fascia lata interposition while those treated for contractures underwent anterior and posterior capsular release with or without fascia lata interposition. Those with elbow instability underwent ligament reconstruction. The device was removed after 6 weeks and seven of the 11 patients were satisfied with the outcome of the operation. Stability could not be achieved in two patients with coronoid fractures that were not reconstructed. One patient did not tolerate the device and requested its removal with subsequent subluxation. We conclude that patient selection and compliance are key elements in achieving a satisfactory outcome with the device.

Ulnar nerve elongation and excursion in the cubital tunnel after decompression and anterior transposition.

We studied the elongation and excursion of cadaveric ulnar nerves during elbow flexion in control conditions and after in situ decompression and anterior subcutaneous transposition. We found that the normal nerve had the greatest elongation (23%) and excursion (14 mm) in the epicondylar groove. Decompression did not alter the excursion, but significantly reduced the elongation in the groove (6%) and increased it proximally (19%). After anterior subcutaneous transposition, the nerve segment which was originally in the groove elongated with elbow extension to the same extent as occurred with the normal nerve during flexion.

Recurrent compressive neuropathy of the median nerve at the wrist: treatment with autogenous saphenous vein wrapping.

Recurrence of symptoms occurs in a significant number of patients after surgical decompression for carpal tunnel syndrome, and its management is both challenging and difficult. Fifteen patients with recurrent carpal tunnel syndrome were treated with a vein wrapping technique using the autologous saphenous vein. A total of 48 operations had been performed on these patients before wrapping the median nerve with a saphenous vein graft. At a mean follow-up of 43 months all patients reported significant pain relief and improvement in their sensory disturbances. Two-point discrimination and the findings of nerve conduction studies also improved.

A simplified method for repair of distal biceps tendon ruptures.

Repair of distal biceps brachii tendon ruptures is recommended for active individuals desiring maximum return of elbow supination and flexion strength. A 2-incision method of repair has been most popular but carries a risk of radioulnar synostosis. In the past, repair through a single anterior incision required more dissection and risked injury to the posterior interosseous nerve. The authors present a simplified method for the repair of distal biceps tendon ruptures through a single anterior incision. The use of suture anchors provides secure fixation to the radius with minimal volar dissection. This method was used successfully in 16 patients, 8 acutely (<6 weeks) and 8 chronically, with excellent functional results. Patients who received acute repairs regained elbow strength and power; patients who received chronic repairs showed slight deficits of supination strength (16%) and flexion power (14%). Of 10 chronic ruptures treated, only 2 tendons could not be mobilized back to the radial tuberosity and had to be transferred to the brachialis. There were no failures and no complications of radioulnar synostosis or posterior interosseous nerve palsy. The single anterior incision approach in which suture anchors are used is recommended as an alternative to the traditional 2-incision method.

Recalcitrant post-surgical neuropathy of the ulnar nerve at the elbow: treatment with autogenous saphenous vein wrapping.

Surgical decompression or transposition is generally efficacious for cubital tunnel syndrome. However, recurrence is not rare and its management is both challenging and difficult. Four patients with refractory cubital tunnel syndrome were operated on with the vein-wrapping technique, using the autologous saphenous vein. A total of 16 operative procedures were performed on these patients prior to wrapping the ulnar nerve with a saphenous vein graft. The mean patient age was 43 years (range: 30 to 54 years) and the mean follow-up was 34 months (range: 24 to 44 months). All patients reported significant pain relief and improvement in sensation. Two-point discrimination and EMG findings also improved. This is the first study reporting long-term results of the vein-wrapping technique for the treatment of recalcitrant cubital tunnel syndrome.

Partial nerve injuries in the upper extremity.

The level of injury of a peripheral nerve is a critical factor that has a great impact on the result of the repair. At the level of the wrist, the median and ulnar nerves have pure motor and sensory fascicular groups. Proximal to the wrist, the motor fascicular groups combine with sensory fascicles and become mixed nerves. Mapping the fascicular orientation with electrical stimulation is indicated for injuries located from the wrist to the distal third of the forearm. Successful application of this technique depends on the level of injury, anesthetic technique, and careful patient selection. Children and patients with other serious coexisting injuries are not candidates for this technique. The depth of anesthesia must provide adequate analgesia while allowing the patient to communicate and cooperate with the surgeon during the procedure. There are few reports in the literature about repair of partially injured nerves in the upper extremities and the comparison of functional outcomes with or without the use of nerve grafts is not easy. Even under ideal operative conditions and with ideal indications, the outcomes are not always satisfactory. Hurst et al reported very good results using end-to-end repair of fascicular groups in their series. Using the rating system of the British Medical Research Council, they reported motor values of 4.0 (normal 5.0), and sensory values of 3.8 (normal 4.0). Kato et al reported very good results in their series of 51 cases with group fascicular end-to-end suture using orientation with electrical stimulation. In this series, there were five patients with partial nerve laceration and end-to-end coaptation of the fascicular groups provided very satisfactory outcome. End-to-end repair of the fascicular groups seems to provide better results than repair of the nerve using nerve grafts. It is desired, however, that the nerve gap be less than 2 cm for the application of end-to-end repair of the nerve.

Trapeziometacarpal arthroplasty using the entire flexor carpi radialis tendon.

Fifty-eight patients (62 joints) with arthritis of the thumb carpometacarpal joint were treated with resection arthroplasty, ligament reconstruction, and tendon interposition with the entire flexor carpi radialis tendon. The mean age of the patients at the time of surgery was 58.4 years (range, 28-80 years), and the average followup was 42.5 months (range, 21-86 months). The entire flexor carpi radialis tendon was used for reconstruction and interposition. In 32 of the 62 joints, a partial trapezoidectomy was performed for scaphotrapezoidal arthritis. Finger-tip pinch improved by 88%, key pinch improved by 86%, and grip strength improved by 69%. Palmar and radial abduction also improved by 8% and 10%, respectively. Fifty-five (95%) patients reported excellent pain relief, whereas three patients reported only mild pain. No patients experienced an increase in pain. All thumbs were stable radiographically. This study indicated ligament reconstruction with tendon interposition, accompanied by partial trapezoidectomy when indicated, provides excellent pain relief and restoration of function. No morbidity was observed with use of the entire flexor carpi radialis tendon.