Nerve grafts and transfers

Following Cruickshank’s (1795) ingenious (and at first disbelieved) demonstration of the regenerative capacity of mammalian nerves, the eighteenth and nineteenth centuries saw a pan-European enthusiasm to redress the nihilism surrounding nerve injury. The first recorded experimental nerve grafts were performed by Philipeaux and Vulpian who attempted both nerve autografting as well as allografting in dogs. At that time, and for many years, allografts were thought to behave similarly to autografts, a belief that persisted well into the twentieth century in some clinics and laboratories. These early attempts at nerve grafting yielded poor results and most surgeons aimed for primary nerve repair despite nerve gaps. Other techniques to allow direct repair involved alteration of position, transposition of the nerve, and even sometimes bone shortening. Although primary repair was frequently possible, after these measures the repair was under tension and mechanical failure was common. Spurling (1945), Whitcomb (1946), and Woodall (1956) showed failure rates of 4%, 7.5%, and 22.4% respectively. Some recovery of function following nerve grafting was documented by Sanders (1942), Seddon (1954), and Brooks (1955). Millesi subsequently published his results for nerve grafting for injuries to the upper limb in 1984. These papers demonstrated more significant recovery of function and highlighted the detriment of delay in treatment to final outcome. Microsurgical advances were central to Millesi’s results, and he emphasized atraumatic dissection and the deleterious effect of tension at the repair site resulting in fibrosis preventing axonal regrowth. Nerve autograft is now the standard for orthotopic nerve reconstruction when primary repair cannot be achieved.

Microvascular free flaps from the lower abdomen for preservation of amputation length in the lower extremity

BACKGROUND: The length of the amputation stump is crucial for optimal prosthetic fitting and rehabilitation. Especially in traumatic amputation, direct closure of the stump may be challenging, and bone shortening is frequently needed. To avoid excessive bone shortening, coverage of exposed bone with free flaps is a versatile option. OBJECTIVE: Here we present our experience with the utilization of free flaps from the lower abdomen for the coverage of amputations stumps of the lower extremity. METHODS: Between March 2008 and October 2010, five patients (three female, two male) with complex wounds on amputation stumps of the lower extremity were treated with a mean age of 50 years (range: 15–72 years). Six abdominal free flaps were performed in five patients (one bilateral case), including four deep inferior epigastric artery (DIEP-) and two muscle-sparing transverse rectus abdominis muscle (ms-TRAM-) flaps. Patient’s and operative data were collected retrospectively. RESULTS: One complete flap failure occurred (overall success rate: 83.3%). Three of five patients gained full ambulatory status. CONCLUSIONS: Due to the low donor site morbidity a long vascular pedicle and the large amount of available tissue, abdominal based free flaps represent our first choice for microsurgical reconstruction of lower extremity stumps.

Shortening Scarf Osteotomy for Macrodactyly and Valgus of the Hallux in Acrodysostosis Lesser Toes Brachydactyly

Acrodysostosis is a rare syndrome of peripheral dysostosis, neurodevelopment delay, and skeletal abnormalities. The most common bone changes are peripheral dysostosis with severe brachydactyly of the lesser toes. The first ray of the feet is often not affected or may present hyperplasia resulting in an unbalanced transverse arch of the forefoot, with potential negative effects on function. Additionally, the insufficiency of the lesser toes may be associated with complex congenital hallux valgus deformities. Surgical approaches include growth plate epiphysiodesis, bulk reduction procedures, bone shortening, osteotomies, or amputation. Here, we report a case of a 14-year-old girl with acrodysostosis and severe discrepancy of the first ray and hallux valgus deformity simultaneously treated by a modified scarf osteotomy. Levels of Evidence Level V: Case report

111 Predicting Restoration of Joint Function in the Contracted Burned Hand: The Benefit of the Soft Tissue to Skeletal Ratio

Introduction Long-standing burn contractures of the hand produce marked soft tissue deficits across mobile joint surfaces. Optimum functional reconstruction requires attention to the ratio of soft tissue contracture to skeletal length. Maturation of burn scar and anticipated growth in children play a role in selecting procedures that maximize function and range. Methods Burn contractures of the hand show functional loss of motion by flexion/extension deformities of the fingers and wrist. Analysis of soft tissue shortening (contraction), measured against existing skeletal length was used to customize procedures to restore maximum function. Twenty six patients, aged 3 to 57 years underwent post burn reconstruction to maximize hand function. Each procedure selected was based on the ratio of existing soft tissue to skeletal length. Results Flexion/extension at all joints requires a balanced glide of soft tissue over existing bone length defining a 1:1 ratio between soft tissue and skeletal length. Burn contracture shortens soft tissue and restricts motion over joints. An objective ratio was applied to each joint contracture. A comparison of soft tissue quality to skeletal length (including growth in children) was used to determine the procedure for reconstruction associated with the best prognosis for maximum outcome with the least recurrence. Abnormalities included post burn boutonniere deformities, webspace contractures, flexion and extension contracture deformities of the hand, and digits. Burn scar hypertrophy and induration worsened the ratio. Eight patients with a soft tissue to skeletal ratio of 0.4:1 or less required bone shortening in the form of either joint arthrodesis, trapeziectomy, or wrist fusion. Twelve patients with a ratio of 0.7:1 or better were managed with skin grafts and/or adjacent tissue rearrangement. In the remaining group, four patients required a combination of procedures including composite soft tissue and tendon expansion restoring length of all soft tissue relative to bony length precluding the need for flap reconstruction and tendon lengthening. Two patients underwent bone shortening with prosthetic joint replacement. All patients restored to a 0.8:1 ratio or better regained optimum position of joint position and function. No secondary procedures were required for deterioration of function at two years. Conclusions A balanced dynamic soft tissue to skeletal ratio is essential in restoring maximum function to the burned hand. Understanding soft tissue contraction compared to existing bone length will permit the objective design of a reconstructive hand/finger procedure that will predict outcome and maximize hand function. Applicability of Research to Practice Predicable outcomes of functional hand reconstruction are possible based on the relationship of burn scar contracture to measurable skeletal length.

Modified anterograde pedicle advancement flap in fingertip injury

Soft tissue reconstruction is needed to maintain the maximum length of the fingers in fingertip injury. The purpose of this study was to present an anterograde pedicle advancement flap technique, for the treatment of fingertip injuries, which involved a modification to the anterograde advancement flap by the dissection of the digital nerve and artery with a pedicle to advance the flap. This technique was used in 12 fingers in patients who had undergone soft tissue reconstruction of fingertip injuries between January 2012 and October 2013. The sizes of the flaps ranged from 8 × 7 mm to 14 × 10 mm. The mean length of advancement was 9.7 mm (range 7–13). The mean value of the static two-point discrimination test of the healed flaps was 5.1 mm (range 4–6) and the flaps survived in all the 12 cases. The modified anterograde pedicle advancement flap provides a reliable coverage of sensate soft tissue without bone shortening in fingertip injuries. Level II