Impact of COVID-19 on hand surgery in Italy: A comparison between the Northern and the Southern regions

The aims of this study were to evaluate the impact of the COVID-19 pandemic on emergency and elective hand surgery in four Italian regions that had either a high (Lombardy and Piemonte) or a low (Sicilia and Puglia) COVID-19 case load to discuss problems and to elaborate strategies to improve treatment pathways. A panel of hand surgeons from these different regions compared and discussed data from the centers they work in. The COVID-19 pandemic had an enormous impact on both elective and emergency surgery in Italy, not only in highly affected regions but also – and paradoxically even at a higher extent – in regions with a low COVID-19 case load. A durable and flexible redesign of hand surgery activities should be promoted, while changing and hopefully increasing human resources and enhancing administrative support. Telematics must also be implemented, especially for delivering rehabilitation therapy.

One bone forearm with vascularized fibular graft. Clinical experience and literature review

One-Bone-Forearm (OBF) is a procedure in which the proximal stump of the ulna is fixed to the distal stump of the radius. Historically, the indications for OBF have been represented by forearm instability due to trauma, infection, tumor resection, and congenital deformities with severe radius and ulna bone loss. When major bone loss prevents direct fixation between ulna and radius a Vascularized Fibular Bone Graft (VFBG) may allow forearm bone reconstruction and fixation. In this study we report our clinical experience in 4 cases of OBF with VFBG performed in 3 patients. Compared to standard OBF technique with direct osteodesis, OBF with VFBG showed similar clinical results and high rate of healing even in case of bone infection. Moreover, composite osteocutaneous VFBG might concurrently allow to treat local soft tissue defects.

Treatment of acute bone defects in severe lower limb Trauma

PURPOSE

To present our experience in the management of acute large bone defects treated with the use of vascularized fibular grafts supported by Ilizarov circular external frames.

PATIENTS AND METHODS

During a period of 6 years (from 2007 to 2013) 8 patients with acute large bone defects (IVB according to Winquist modified classification) were treated at our institution with early bone reconstruction by means of microvascular fibular grafts. All patients were evaluated by the use of the following parameters: X-ray consolidation, discharge time, duration of treatment, malalignment of the lower limb and final leg length discrepancy, knee and ankle mobility (ROM), pain (VAS), number of eventual additive treatments (plastic surgery, etc.), walking independence (use of crutches), possibility to get back to work, subjective evaluation about the treatment and the result (SF-36, personal feelings about circular external fixator dressing) RESULTS: The mean treatment time, often connected to the mean consolidation time, was 61 weeks and the mean number of operations was 7.6. Six of the eight patients got back to their previous daily activities and work, without any further issues.

DISCUSSION

based on our experience, Ilizarov and fibular vascular grafts are not alternatives, as often reported in literature. Their combined use, especially in lesions as those classified as Winquist IV B, can represent an effective tool in the surgeon's hands to solve the most difficult cases of acute bone loss caused by severe high-energy traumas.

Free composite groin flap to solve a complex loss of tissue in a traumatic injury of the foot: A case report

Severe traumatic losses of soft tissues and bone at foot and ankle level are often treated by means of amputation, but this may involve important psychological and anatomic consequences for the patient. If there are good vascular conditions, reconstruction by means of composite free flaps is often the only alternative to this demolitive treatment. The transfer of composite free flaps that include vascularized bone from various donor sites may provide anatomical reconstruction and recovery of function of the foot and ankle. If plantar skin and its sensation are present, these techniques may represent a good choice in the treatment of complex injuries of the foot, and by means of skeletal morphological reconstruction, they may give good functional results. With these premises, we report a case in which was used a groin flap to fill and solve a complex defect of bone and soft tissues of midfoot in a gunshot injury.

The role of the FESSH Hand Trauma Committee in Europe

In Europe the need for clear definitions of hand surgery facilities regarding trauma is becoming really important to guarantee a correct and up-dated treatment of lesions more and more frequent and complex. The goal for European patients should be to have similar treatment based on appropriate referral and assistance in centres officially accredited for hand surgery. The target for the European countries, giving the correct support to the centres and surgeons treating these problems, should also be to save the costs of residual invalidities. These are some of the reasons for the European Federation of Societies for Surgery of the Hand (FESSH) decided to form a committee (Hand Trauma Committee) devoted to study this problem, trying to give common guidelines and forming an European net of accredited centres. The first step was to collect data through a network of national representatives. Covering a 487 millions population, 309 centres were recorded, including 1 797 surgeons and 20 363 patients treated during January 2006, then having a clear situation of hand trauma treatment through Europe. Next, the HTC worked on 3 definitions: hand trauma, hand trauma surgeons and hand trauma centres and started to accredit centres applying to these well defined criteria. The HTC is now working on scientific consensus on some traumatic lesions but also on the important topic of prevention of hand traumas. This work is expected to improve an homogenous situation throughout Europe focusing on the better use of the given resources for the prevention and the treatment of these traumatic lesions.

Perineural fat grafting in the treatment of painful end-neuromas of the upper limb: a pilot study

The purpose of this study was to evaluate the effectiveness and middle-term durability of the results achieved with perineural fat grafting of painful neuromas of the upper limb. We retrospectively analysed eight patients, affected by eight neuromas, treated by neuroma excision and fat grafting around the proximal nerve stump. Clinical parameters, the disabilities of the arm shoulder and hand score, and the visual analogue scale were recorded at 2, 6 and 12 months after surgery. A reduction of 23.2% was observed in the mean disabilities of the arm shoulder and hand scores at 12 months. The spontaneous baseline visual analogue scale score showed a mean improvement of 22% at 12 months, although not this was not statistically significant. Perineural fat grafting is a quick and useful procedure and could represent a useful primary operation in the treatment of pain syndromes of neuropatic origin.

Efficiency of Hyaloglide in the prevention of the recurrence of adhesions after tenolysis of flexor tendons in zone II: a randomized, controlled, multicentre clinical trial

Hyaloglide is a hyaluronan-based gel based on a novel auto-crosslinked technology designed to reduce postsurgical adhesions. Its efficacy was assessed in a multicentred randomized controlled trial comparing the results of flexor tenolysis in zone 2 following failed flexor tendon repairs. In the control group a standard release was performed. In the treated group, Hyaloglide was applied into the flexor sheath and around the site of tenolysis. Forty-five patients, 19 controls and 26 treated with Hyaloglide, were enrolled in 13 centres. All the patients were evaluated at 30, 60, 90 and 180 days after surgery by testing Total Active Motion, Quick-DASH questionnaire and number of working days lost after surgery. Patients in the Hyaloglide group had a statistically better recovery of finger motion at all time intervals and returned earlier to work and daily activities. The use of Hyaloglide did not appear to increase the complication rate.

Termino-lateral nerve suture in lesions of the digital nerves: clinical experience and literature review

Documented experience of treatment of digital nerve lesions with the termino-lateral (end-to-side) nerve suture is limited. Our clinical experience of this technique is detailed here alongside a systematic review of the previous literature. We performed, from 2002 to 2008, seven termino-lateral sutures with epineural window opening for digital nerve lesions. Functional outcome was analysed using the two-point discrimination test and the Semmes-Weinstein monofilament test. The results showed a sensory recovery of S3+ in six cases and S3 in one case. The mean distance found in the two-point discrimination test was 12.7 mm (range 8-18 mm). After a review of the literature, we were able to obtain homogeneous data from 17 additional patients operated by termino-lateral coaptation. The overall number of cases included in our review was 24. A sensory recovery was observed in 23 out of 24 patients. The functional results were S0 in one case, S3 in one case, S3+ in twenty cases and S4 in two cases. Excluding the one unfavourable case, the mean distance in the two-point discrimination test was 9.7 mm (range 3-18 mm). It can thus be concluded that the treatment of digital nerve lesions with termino-lateral suture showed encouraging results. Based on the results obtained in this current study we believe that in case of loss of substance, end-to-side nerve coaptation may be an alternative to biological and synthetic tubulisation when a digital nerve reconstruction by means of nerve autograft is declined by the patient.

End-to-side nerve suture in traumatic injuries of brachial plexus: review of the literature and personal case series

We used end-to-side nerve coaptation combined with standard end-to-end neurotisations to treat 11 patients who presented with complete (six cases) or incomplete (five cases) traumatic brachial plexus injuries. All patients were available for functional evaluation at a minimum of 2 years postoperatively. In three patients with shoulder abduction recovery, electromyographical studies (EMG) showed a contribution from the end-to-side neurotisation. In the remaining cases end-to-side neurotisations were unsuccessful. Our study did not demonstrate a reliable role for end-to-side nerve suture in brachial plexus surgery. We believe that at present end-to-side suture must not be a substitute for standard reconstructive techniques in brachial plexus surgery. Occasionally termino-lateral nerve sutures may represent a support to standard reconstructive procedures especially in case of severe injuries when few undamaged donor nerves are available.

A simple sterile polypropylene fingernail substitute

Traumatic nail injuries are often observed in clinical practice. Usually the fingernail can be preserved, cleaned and disinfected in order to use it in the reconstructive procedure. However, in some cases the nail can be avulsed and lost or too damaged to be used. In cases when the nail is not available it should be replaced by a substitute in order to protect nail bed and avoid adherences along the proximal nail bed and the nail fold. Furthermore the substitute serves to protect the tender nail bed from painful stimuli during the healing process. We used, as fingernail substitute, a polypropylene sheet in eight patients with fingernail avulsion or disruption. The polypropylene foil was trimmed reproducing the profile of the avulsed fingernail and thinned at the proximal edge to reduce thickness in order to ease the insertion into the nail fold. A small hole was then created in the center of the foil to allow blood drainage. The substitute was usually removed one month after the application. In our clinical experience we had not complications related to the polypropylene device. The new fingernail had good cosmetic appearance in most cases and all the patients reported a good protection of the fingertip during the healing period. The substitute used in this series is sterile, inexpensive and easily available in emergency and elective operatory theater. This polypropylene foil is flexible and can be shaped and adapted to the nail curvature radius. The substitute used in our clinical series protected the nail bed during healing until the growth of the new fingernail and respected our functional expectations.

Piezosurgery in head and neck oncological and reconstructive surgery: personal experience on 127 cases

Piezoelectric bone surgery, known simply as piezosurgery, is a new technique of osteotomy and osteoplasty, which requires the use of microvibrations of ultrasonic frequency scalpels. The principle of piezosurgery is ultrasonic transduction, obtained by piezoelectric ceramic contraction and expansion. The vibrations thus obtained are amplified and transferred onto the insert of a drill which, when rapidly applied, with slight pressure, upon the bony tissue, results, in the presence of irrigation with physiological solution, in the cavitation phenomenon, with a mechanical cutting effect, exclusively on mineralized tissues. Personal experience with the use of piezosurgery in head and neck oncological and reconstructive surgery is relatively recent, having been developed in 2002-2006, and, so far, involves 127 cases; preliminary results are interesting and improving in the, hopefully, developmental phases of inserts with specific geometrics on account of the characteristics of the various aspects of surgical ENT operations. Furthermore, with piezoelectric surgery it has been possible to perform precise osteotomy lines, micrometric and curvilinear with absolute confidence, particularly in close proximity to the vessels and nerves and other important facial structures (dura mater). There can be no doubt, since this is a new cutting method, that piezosurgery involves a different learning curve compared to other techniques, requiring obstacles of a psychological nature to be overcome as well as that concerning surgical expertise. Given the numbers of cases treated and the relative power of this instrument, analysis of complications, intra-operative time (which would appear, on average, to be 20% longer) and, therefore, morbility, shows interesting potentiality of the technique. This new ultrasound cutting method will, no doubt, in the future, be increasingly used in ENT surgery, particularly with improvements in power and geometry of the inserts, with possible applications also in neurosurgery, paediatric surgery and orthopedics, branches in which a selective action upon the mineralized tissues is of fundamental importance.

Functional and morphological assessment of a standardized crush injury of the rat median nerve

The availability of effective experimental models for investigating nerve regeneration and designing new strategies for promoting this unique repair process is important. The aim of this study was to standardize a rat median nerve crush injury model using a non-serrated clamp exerting a compression force of 17.02 MPa for a duration of 30s. Results showed that functional recovery, evaluated by grasping test, was already detectable at day-12 and progressively increased until day-28 after which animal performance plateaued until the end of testing (day-42), reaching a range of 75-80% of pre-operative values. Morphological analysis on the median nerve segments, distal to the crush lesion, which were withdrawn at the end of the experiment showed that regenerated nerve fibers are significantly more numerous and densely packed; they are also smaller and have a thinner myelin sheath compared to controls. Together, these results provide a baseline characterization of the crush median nerve injury experimental model for its employment in the investigation of nerve regeneration research, especially when a reproducible regeneration process is required, such as for the study of biological mechanisms of peripheral nerve fiber regeneration or development of new therapeutic agents for promoting posttraumatic nerve repair.

Comparison of fresh and predegenerated muscle-vein-combined guides for the repair of rat median nerve

Over the last 10 years, we have investigated a particular type of bioengineered nerve guide, the muscle-vein-combined tube, which is made by filling a vein with skeletal muscle. In our previous studies we have always used fresh skeletal muscle to fill vein conduits. In the present study we compared the use of fresh and predegenerated (freeze-thawed) skeletal muscle for muscle-vein-combined nerve guides. In this study, a 10-mm-long rat median nerve defect was repaired using either type of nerve guide. The samples were analyzed 5 and 30 days after surgery by light and electron microscopy. In addition, reverse transcription polymerase chain reaction (RT-PCR) was carried out to investigate the expression of mRNAs coding for glial markers, as well as glial growth factor (NRG1) and its receptors (erbB2 and erbB3). Results showed differences between the two types of nerve guides at postoperative day 5; however, no difference was detected at day 30 suggesting that both types of tissue-engineered conduit are effective for repairing peripheral nerve defects in this experimental model.

Nerve regeneration along bioengineered scaffolds

Tissue engineering has recently seen great advancements in many medical fields, including peripheral nerve reconstruction. In the rat median nerve model, we investigated nerve repair by means of bioengineered tissue scaffolds (muscle-vein-combined tubes) focusing on changes in the neuregulin-1/ErbB-receptor system which represents one of the main regulatory systems of axo-glial interaction in peripheral nerves. Repaired nerves were withdrawn at 5, 15, and 30 days postoperative and processed for morphological and retro-transcriptase polymerase chain reaction (RT-PCR) analysis. Results revealed an early and progressive increase in the expression of NRG1alpha isoform only, while the appearance of the beta isoform of NRG1, which is normally present in peripheral nerves, was delayed. In regards to ErbB2 and ErbB3 receptors, their expression increased progressively inside the muscle-vein-combined scaffolds, though with different kinetics. Taken together, these results suggest that variations in neuregulin-1/ErbB system activation play a key role in peripheral nerve regeneration along bioengineered muscle-vein-combined scaffolds. Since similar variations are also detectable in denervated skeletal muscles, it can be hypothesized that the existence of a NRG1's autocrine/paracrine trophic loop shared by both glial and muscle fibers could be responsible for the effectiveness of muscle-vein-combined conduits for repairing nerve defects.

Low-power laser biostimulation enhances nerve repair after end-to-side neurorrhaphy: a double-blind randomized study in the rat median nerve model

Previous studies have shown that low-power laser biostimulation (lasertherapy) promotes posttraumatic nerve regeneration. The objective of the present study was to investigate the effects of postoperative lasertherapy on nerve regeneration after end-to-side neurorrhaphy, an innovative technique for peripheral nerve repair. After complete transection, the left median nerve was repaired by end-to-side neurorrhaphy on the ulnar "donor" nerve. The animals were then divided into four groups: one placebo group, and three laser-treated groups that received lasertherapy three times a week for 3 weeks starting from postoperative day 1. Three different types of laser emission were used: continuous (808 nm), pulsed (905 nm), and a combination of the two. Functional testing was carried out every 2 weeks after surgery by means of the grasping test. At the time of withdrawal 16 weeks postoperatively, muscle mass recovery was assessed by weighing the muscles innervated by the median nerve. Finally, the repaired nerves were withdrawn, embedded in resin and analyzed by light and electron microscopy. Results showed that laser biostimulation induces: (1) a statistically significant faster recovery of the lesioned function; (2) a statistically significant faster recovery of muscle mass; (3) a statistically significant faster myelination of the regenerated nerve fibers. From comparison of the three different types of laser emissions, it turned out that the best functional outcome was obtained by means of pulsed-continuous-combined laser biostimulation. Taken together, the results of the present study confirm previous experimental data on the effectiveness of lasertherapy for the promotion of peripheral nerve regeneration and suggest that early postoperative lasertherapy should be considered as a very promising physiotherapeutic tool for rehabilitation after end-to-side neurorrhaphy.

Schwann-cell proliferation in muscle-vein combined conduits for bridging rat sciatic nerve defects

Among the various grafting procedures that have been studied as alternatives to traditional fresh nerve autografts for the repair of severed peripheral nerves, muscle-vein-combined graft conduits have recently been devised and successfully employed. In the present study, the early presence, origin, and proliferation activity of Schwann cells (SCs) along this particular type of biological graft conduit have been investigated, using antibodies directed against glial fibrillar acid protein (GFAP), a protein that is specifically expressed in glial cells, and proliferating cell nuclear antigen (PCNA), a protein that is expressed by cells during DNA synthesis. Results showed that the muscle-vein-combined graft was progressively invaded by a number of GFAP-immunopositive SCs, many of which were also found to be immunopositive for PCNA, thus demonstrating that their proliferation continues to occur inside the graft. Among the molecules that could be involved in the stimulation of Schwann-cell proliferation is neuregulin-1 (NRG-1) that mediates its effects by binding to the ErbB receptor tyrosine kinase family. In the present study, the authors report on the RT-PCR analysis for NRG-1 and ErbB3 mRNAs, showing an overall increase in the content of these transcripts inside the muscle-vein-combined graft. These results suggest that the muscle-vein-combined graft conduit constitutes an environment favorable to potentiate Schwann-cell proliferation during the early regeneration phases.

Management of neuromas in continuity of the median nerve with the pronator quadratus muscle flap

Treatment of painful neuromas in continuity of the median nerve at the wrist level is a challenging problem. Nine median nerve neuromas were covered with the pronator quadratus muscle preelevated as an island flap. Patients were followed for 10 to 60 months after surgery. Results showed a marked improvement in terms of symptoms in all patients. In particular, 6 patients had complete pain relief and 3 patients complained of mild intermittent pain.

Confocal imaging of Schwann-cell migration along muscle-vein combined grafts used to bridge nerve defects in the rat

Schwann cells guide axonal regrowth during peripheral nerve repair. In a case of a nerve lesion with substance loss, a graft conduit is necessary to enable axons to reach the distal nerve stump. If a non-nervous autograft is used, the question arises as to the presence and origin of Schwann cells along the grafted tube. We addressed this issue using a tubulization technique based on the use of an autologous vein filled with fresh skeletal muscle for the repair of sciatic nerve defects in the rat. We showed that both ends of the graft were early and progressively colonized by a number of glial fibrillar acid protein-immunopositive and S-100 immunonegative cells, an immunocytochemical pattern typical of immature Schwann cells. These cells, which were located in the interstice between grafted skeletal muscle fibers, are mainly organized into long chains oriented along the main axis of the graft and progressively colonize all the graft. Schwann cells coming from the distal nerve end are suitable for being responsible for guiding regeneration of nerve fibers along the graft toward the correct periphery (tissue specificity).

Methodological issues in size estimation of myelinated nerve fibers in peripheral nerves

Size estimation of myelinated nerve fibers in peripheral nerves is a very common task in neuromorphology and different dedicated morpho-quantitative procedures have been devised and used to date. Unfortunately, many reports on experimental nerve studies lack comprehensive information on the procedures that have been designed and applied for myelinated fiber size estimation. This paper addresses the issue in the light of the recent advances in quantitative morphology that have recognized the concept of unbiased estimates as the key methodological issue to be addressed in morpho-quantitative studies. The potential foundations of bias at various study levels are analysed together with indications on how to cope with them. In addition, the issue of the precision of size estimates is addressed and the various geometrical parameters that can be selected for myelinated nerve fiber size assessment are outlined. Taken together, information provided in this paper is expected to help investigators conduct an appropriate preliminary study design phase, the key step for setting up the most adequate morpho-quantitative procedure for any given research goal.

Tissue specificity in rat peripheral nerve regeneration through combined skeletal muscle and vein conduit grafts

Diffusible factors from the distal stumps of transected peripheral nerves exert a neurotropic effect on regenerating nerves in vivo (specificity). This morphological study was designed to investigate the existence of tissue specificity in peripheral nerve fiber regeneration through a graft of vein filled with fresh skeletal muscle. This tubulization technique demonstrated experimental and clinical results similar to those obtained with traditional autologous nerve grafts. Specifically, we used Y-shaped grafts to assess the orientation pattern of regenerating axons in the distal stump tissue. Animal models were divided into four experimental groups. The proximal part of the Y-shaped conduit was sutured to a severed tibial nerve in all experiments. The two distal stumps were sutured to different targets: group A to two intact nerves (tibial and peroneal), group B to an intact nerve and an unvascularized tendon, group C to an intact nerve and a vascularized tendon, and group D to a nerve graft and an unvascularized tendon. Morphological evaluation by light and electron microscopy was conducted in the distal forks of the Y-shaped tube. Data showed that almost all regenerating nerve fibers spontaneously oriented towards the nerve tissue (attached or not to the peripheral innervation field), showing a good morphological pattern of regeneration in both the early and late phases of regeneration. When the distal choice was represented by a tendon (vascularized or not), very few nerve fibers were detected in the corresponding distal fork of the Y-shaped graft. These results show that, using the muscle-vein-combined grafting technique, regenerating axons are able to correctly grow and orientate within the basement membranes of the graft guided by the neurotropic lure of the distal nerve stump.

Morphological analysis of peripheral nerve regenerated by means of vein grafts filled with fresh skeletal muscle

Clinical data have shown that a vein segment filled with fresh skeletal muscle can be considered a good autologous grafting conduit for the repair of peripheral nerve lesions. In this study, the long-term morphological organization of rat sciatic nerve fibers regenerated along a muscle-vein-combined graft conduit is further analysed by light and electron microscopy. Regenerated nerve fibers were organized into fascicles of various sizes that were clearly delimited by perineurial-like shells made by long and thin cytoplasmic processes of perineurial-like bipolar cells and by densely packed collagen fibrils. Grafted skeletal muscle fibers were still detectable among nerve fiber fascicles. However, in spite of the persistence of skeletal muscle along the graft, regenerated nerve fibers showed a good morphological pattern of regeneration, providing further evidence that the muscle-vein-combined grafting technique represents an effective surgical alternative to the classical fresh nerve autograft for the repair of peripheral nerve defects.

A stereological study of long-term regeneration of rat severed sciatic nerve repaired by means of muscle-vein-combined grafts

This study is a stereological analysis, by the 2-D dissector method, on the long-term regeneration of myelinated nerve fibers of the rat sciatic nerve repaired by muscle-vein-combined graft, a surgical technique that has been shown to be a valid tool for the repair of peripheral nerve defects with substance loss. Quantitative analysis showed that the total number and mean density of regenerated myelinated nerve fibers was significantly higher than in control nerves. The contrary was true for fiber mean size. The morpho-quantitative parameters of regenerated fibers from nerves repaired by the muscle-vein-combined graft were similar to those observed in rats where nerve defects were repaired by direct nerve suture thus confirming the validity of this surgical technique.

Nerve repair by means of vein filled with muscle grafts I. Clinical results

Peripheral nerve lesions with a long segment defect need a grafting conduit to heal. Although autogenous nerve grafting is still considered the best method for bridging nerve defects, several alternative types of conduits (biological and synthetic) have been studied. We have demonstrated in previous experimental research in rats that a graft made using a vein (providing a guide for nerve regeneration) filled with fresh skeletal muscle (to prevent vein collapse and support axon regeneration) gave similar results to traditional nerve grafts. On this basis, we decided to use the muscle-vein-combined grafts in clinical cases. From 1993 to 1997, this technique was applied for bridging both sensory and mixed nerve defects (21 cases). We report good results in 85% of our cases with a minimum follow-up of 14 months. These results, obtained on nerve defects ranging from 0.5 to 6 cm in length, seem to be superior to those reported with other kinds of artificial or biological conduits.

Nerve repair by means of vein filled with muscle grafts. II. Morphological analysis of regeneration

The morphological features of regeneration in long-distance (3 cm) muscle-vein-combined grafts were experimentally investigated in the rat sciatic nerve by means of light and electron microscopy. In the early phases of regeneration (14 days after surgery), many regenerating nerve fibers were detected along the muscle-vein-combined graft. Six months after surgery, quantitative morphometrical analysis of myelinated nerve fibers showed that both the total number and density of myelinated nerve fibers were significantly greater in regenerated nerves than in control nerves. The contrary appeared true for the mean fiber size, with fiber size significantly smaller in regenerated nerves. Ultrastructural observations allowed the description of some peculiar aspects of the relationship between muscle fibers, nerve fibers, and Schwann cells in both early and late phases of regeneration.

Verification of the two-dimensional disector, a method for the unbiased estimation of density and number of myelinated nerve fibers in peripheral nerves

Quantification of the number of myelinated fibers in peripheral nerves is a common requirement in quantitative morphology. This parameter provides important information on the consequences of various physiological, pathological and experimental conditions on the nerve structure and is one of the main indicators of success of peripheral nerve repair. In this paper, the theoretical rationale for the application of stereological principles to obtain unbiased estimates of the density and total number of myelinated fibers in peripheral nerves is discussed and a simple stereological method is described. The method is applied together with a systematic random sampling scheme, that was optimized for the purposes of the present study, and with sampling scheme analysis by calculating the coefficient of error (CE). The stereological method, which consists of a two-dimensional variation of the classical disector procedure (two-dimensional disector), and the sampling scheme are verified by comparing estimates with the true density and total number of myelinated fibers in peripheral nerve trunks where true values have been accurately determined by extensive counting. The verification of the 2-D disector method, both of normal and regenerated nerves, showed that estimates of density and total number of myelinated nerve fibers are unbiased. The method also proved to be efficient (time-saving): Estimation of density and total number of myelinated fibers in a single nerve takes about 2-3 hours.

Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer

Ulnar nerve lesions around the elbow often carry an unfavorable prognosis due to insufficient sensory and intrinsic muscle recovery. We present a series of 7 cases in which restoration of ulnar innervated intrinsic muscles of the hand and of skin sensibility was achieved. This was accomplished by a distal connection of the anterior interosseous nerve and the superficial sensory palmar branch of the median nerve to the motor and sensory components of the ulnar nerve at Guyon's canal. The length of the follow-up period ranged from 1 to 3.5 years. Results were graded by the Highet-Zachary scale. Good motor and sensory recovery was obtained in 6 cases; only return of protective sensation occurred in the remaining case.

Assessment of vascularized fibular graft one year after reconstruction of the wrist after excision of a giant-cell tumour

We report a patient in whom the distal radius was resected for a giant cell tumour and the bone defect was replaced using a vascularized proximal fibular graft. The graft was viable and hypertrophied and normal callus formed on the distal radius. Due to chronic instability of the wrist the patient underwent revision arthrodesis 1 year after resection. Microscopic studies of the epishyseal region of the fibula showed wide necrosis of the graft with active creeping substitution. Despite the good technical result of the vascularized fibular graft, the vascularization was incomplete in the proximal epiphysis. We discuss possible reasons for this.

The role of allopurinol in preventing oxygen free radical injury to skeletal muscle and endothelial cells after ischemia-reperfusion

One of the most important mechanisms in the production of ischemic damage after replantation surgery is the rise of oxygen free radicals during revascularization of ischemic tissues. Free radicals produce damage in the cell membranes (lipoperoxydation). This occurs not only in muscle tissue, but also in endothelial cells, with a consequent increase of local edema and the risk of compartment syndrome. This study attempted to interrupt the ischemic-reperfusion injury process in ischemic rat hindlimbs. Complete ischemia was induced for different numbers of hours (3, 6, 9, 12 hr) in four groups of rats (24 animals in each group). Allopurinol, an oxygen free radical scavenger, was tested in solution, 12.5 mg/kg b.w., in half the studied animals (n = 12). Collected data showed an increase (mean value: 0.60 nM/mg 3 hri 0.90 nM/mg at 6 hr; 0.80 nM/mg at 9 hr; 0.89 nM/mg at 12 hr; mean value in nonischemic muscle = 0.526 nM/mg) in lipoperoxides (NS between treated/untreated groups, p > 0.05) and high tissue pressure values in the posterior compartment of the ischemic rat hindlimbs. Allopurinol reduced the pressure values (p < 0.05 in Groups 1-3; p < 0.1 in Group 4), but was not effective in reducing lipoperoxides in skeletal muscle.

Coracoacromial ligament: a comparative arthroscopic and anatomic study

An anatomic study of the coracoacromial ligament was conducted. The data collected from 20 anatomical preparations and the arthroscopic findings in 40 cases were compared. The shape and the tension of the ligament were evaluated, as well as the thickness. Anatomic tradition describes the ligament as a fibrous triangular lamina inserted with its apex on the acromial tip and its base on the lateral edge of the coracoid. It simply closes the coracoacromial arch and has no mechanical role. However, our observations suggest that the ligament has a trapezoidal shape and is situated below the acromion with a wide reflex portion. Its thickness varies from 2 to 5.6 mm. Given that structure, the ligament appears like a robust suspension structure of the coracoid, which contrasts the action of the muscles that connect to it. From these observations, a pathogenic hypothesis of the subacromial impingement proposes itself.

Bridging nerve defects with combined skeletal muscle and vein conduits

The use of vein or muscle grafts to bridge nerve defects longer than 1-1.5 cm gives poor results. Veins collapse and in muscle grafts axons may regrow outside the graft. We used veins (to guide regeneration) filled with muscle (to avoid vein collapse). Nerve regeneration through 1 and 2 cm grafts made of vein plus muscle was compared with similarly long traditional nerve grafts, free fresh muscle grafts, and empty vein grafts. Regeneration was assessed clinically and histologically (qualitative and quantitative evaluation) in the graft and distal nerve stumps. Vein plus muscle grafts were superior to vein and fresh muscle grafts both functionally and histologically. Functional results were similar to those found in traditional nerve grafts, but axon number was superior in the veins filled with muscle. This suggests that vein filled with muscle might serve as a grafting conduit for the repair of peripheral nerve injuries and could give better results than traditional nerve grafting.

Gnostic rings: usefulness in sensibility evaluation and sensory reeducation

The benefit of additional clinical tools for quantifying patients' ability to recognize objects is clear, as well as its correlation with the moving two-point discrimination test. The recognition of letters is such a tool. The authors describe gnostic rings, an additional technique, that is useful for clinical sensibility testing, as well as for sensory reeducation.

Compartmental syndrome due to viper bite

The case is reported of a young girl who was bitten on the hand by a viper and developed compartment syndrome of the intrinsic muscles more than 24 h later. Multiple dorsal and volar fasciotomies resolved the acute episode with complete restitutio ad integrum. The clinical case is discussed in detail and the literature on these rare complications of snake bites in European countries reviewed.

Free microvascular fibular versus conventional bone grafts

Free microvascular grafts have many advantages over conventional bone grafts. Above all they do not undergo creeping substitution and live on their own vessels, thus being able to heal quickly and fight infection. Research in rabbits has been done with radiographic, scintigraphic and light and fluorescence histologic examination which demonstrated the high superiority of quality, reliability and rapidity in healing of the microvascular bone transfer as related to avascular ones. Eighty-five cases of free microvascular fibular transfers starting in 1975 are presented including six congenital cases, 12 non-unions, eight osteitis, seven tumors, seven large losses of bone and 45 femoral head necrosis. The failure ratio is very low. Six primary failures were cured by plaster or additional cancellous bone grafts. Four failures (in femoral head necrosis) did not cure due to recession of the graft, its reabsorption or progression of avascular necrosis in two corticosteroid cases.

Experimental investigation of cross-nerve transfers relating to repair of brachial plexus avulsion injuries

There is a lack of agreement regarding the potential for peripheral nerve cells with short axons to regenerate and innervate the terminal end organs of nerve cells with long axons. We designed a study to evaluate experimentally the possibility of neurons to reconstitute much longer axonal segments. Twenty Wistar rats were used. The brachial plexus was isolated and the radial nerve transected immediately after its origin. The proximal end of the axillary nerve (previously cut) then was coapted tot he distal stump of the radial nerve. In 10 other rats, the cut radial nerve was simply recoapted to itself without involvement of the axillary nerve; these animals served as controls. Finally, in 10 rats, nerves were cut without repair to evaluate the degenerative changes. After 90 days, the distal part of the radial nerve was examined by light microscopy, calculating the number and area of regenerated axons. We also checked the motor end-plates of reinnervated muscles. In the nerve-transferred group, good axonal regeneration with good reinnervation of the muscles was seen. In this way, we have experimentally demonstrated a plasticity of regeneration in peripheral nerves. This suggests that the surgeon may use nerves connected to proximal muscles to neurotize avulsed nerves of distal muscles.

[Proposal for a global medico-legal functional evaluation of disabilities of the hand]

The present evaluations of hand invalidity are based on parameters that can give correct assessment for amputations or for single stiffness, but these parameters are not able to evaluate the majority of lesions. A nerve lesion does not repair at 100% or at 0%; all degrees are possible. The same is true for vascular, tendon and muscular lesions. We studied a new global evaluation on a large number of patients and we compared it with the tables in use today. The assessed parameters are: the active and passive movement, ability of the hand, strength, duration of the effort or of the fatigue, trophism, sensibility, pain, aesthetics.

Traumatic aneurysms of two proper digital arteries in the same patient: a case report

Aneurysms in the hand are infrequent and aneurysms of the proper digital arteries are particularly rare, only 11 cases having been reported in the literature. The authors describe the case of a patient operated on for two traumatic false aneurysms of the ulnar digital arteries of the middle and ring fingers. Arterial aneurysms should be carefully evaluated to exclude other lesions such as cysts, abscesses, neuromas. The choice between ligation and resection or reconstruction of the vessel should be based on pre-operative and intra-operative evaluation of circulation.

Traumatic Aneurysms of Two Proper Digital Arteries in the Same Patient: A Case Report

Aneurysms in the hand are infrequent and aneurysms of the proper digital arteries are particularly rare, only 11 cases having been reported in the literature. The authors describe the case of a patient operated on for two traumatic false aneurysms of the ulnar digital arteries of the middle and ring fingers. Arterial aneurysms should be carefully evaluated to exclude other lesions such as cysts, abscesses, neuromas. The choice between ligation and resection or reconstruction of the vessel should be based on pre-operative and intra-operative evaluation of circulation.

A comparison of vascularized and nonvascularized bone transfer in rabbits: a roentgenographic, scintigraphic, and histologic evaluation

Extensive bone defects caused by bone tumor resection, osteomyelitis, congenital pseudoarthrosis, post-traumatic bone loss, or femoral head necrosis, require large bone grafts. Such large defects usually are not amenable to conventional, nonvascularized cancellous grafts. By using vascularized bone grafts that do not undergo creeping substitution, that heal rapidly and are not depending on the surrounding tissue, better, safer, and faster results can be obtained. To compare recoveries after vascularized grafts with those after conventional, nonvascularized grafts, experiments were carried out in a rabbit model. They demonstrated good viability and better and faster healing of the microvascular grafts, using radiography, scintigraphy, light microscopy of bone osteocytes and vessels, and tetracycline double-labeling evaluation techniques.