Jean-Philippe A. Nicolai

In vivo three-dimensional reconstruction of human median nerves by diffusion tensor imaging.

The in vivo assessment of axonal projections of the peripheral nervous system has been severely limited by the lack of noninvasive techniques. We examined whether MR diffusion tensor imaging with fiber tracking of the human median nerve is feasible. The median nerve was examined with a 3-T MRI scanner in wrists of three healthy volunteers and the wrist of a patient after median nerve repair. In vivo three-dimensional (3D) reconstruction of axonal projections of the median nerve could be achieved in healthy volunteers with intact median nerves and a patient with a transected median nerve using diffusion tensor imaging combined with fiber tracking. The median nerve could be visualized and correlated well to the expected location on T1-weighted images in the patient and all volunteers. The transected median nerve in the patient could be detected up to the site of repair one month postoperatively, whereas the nerve could not be detected more distally immediately after repair. Two months postoperatively, it could clearly be tracked more distally, indicating nerve regeneration. Diffusion tensor imaging can detect the median nerve in healthy individuals as well as up to the lesion site in a patient with a complete transection of the median nerve.

Effects of motor imagery on hand function during immobilization after flexor tendon repair.

OBJECTIVE To determine whether motor imagery during the immobilization period after flexor tendon injury results in a faster recovery of central mechanisms of hand function. DESIGN Randomized controlled trial. SETTING Tertiary referral hospital. PARTICIPANTS Patients (N=28) after surgical flexor tendon repair were assigned to either an intervention group or a control group. INTERVENTION Kinesthetic motor imagery of finger flexion movements during the postoperative dynamic splinting period. MAIN OUTCOME MEASURES The central aspects of hand function were measured with a preparation time test of finger flexion in which subjects pressed buttons as fast as possible following a visual stimulus. Additionally, the following hand function modalities were recorded: Michigan Hand Questionnaire, visual analog scale for hand function, kinematic analysis of drawing, active total motion, and strength. RESULTS After the immobilization period, the motor imagery group demonstrated significantly less increase of preparation time than the control group (P=.024). There was no significant influence of motor imagery on the other tested hand function (P>.05). All tests except kinematic analysis (P=.570) showed a significant improvement across time after the splinting period (P</=.001). CONCLUSIONS Motor imagery significantly improves central aspects of hand function, namely movement preparation time, while other modalities of hand function appear to be unaffected.

The osmotic tissue expander : a three-year clinical experience

Closure of defects after trauma or excision of neoplasms is a basic skill in plastic surgery. Local, regional and distant flaps lead to additional scars. Skin recruitment by serial excision or skin expansion is a less damaging option for defects that must be closed. Advantages of tissue expansion include good colour and texture match. Disadvantages are the need for a second operation, use of an implant with the attendant risk of infection, time needed for inflation of the device, repeat visits to the clinic, and punctures to inflate the expander. To overcome the last disadvantage, an osmotic expander was developed in Germany in 1999 by OSMED GmbH (Ilmenau).

A family with complex bilateral polysyndacty

A six-generation family with 88 members is described. A curious combination of polydactyly, syndactyly, and triphalangeal malformed thumbs affected about 30% of the members. It is believed that this congenital hand deformity only occurs in an hereditary form.

Rehabilitation strategy using enhanced housing environment during neural regeneration

The influence of an enriched environment on the recovery of nerve function was studied after a sciatic nerve lesion and repair. A sciatic nerve gap of 15 mm was bridged in 12 rats using autologous nerve grafts. The rats were housed either in an enriched environment or in standard cages. In the enhanced housing environment, the rats were forced to move by dissociating food and water sources, including wire for foot gripping instead of flat plastic floors, and wooden play toys. Locomotor behavior was recorded on tape with a digital videorecorder and behavioral data were compared with those of a group of six unoperated rats. The video-recordings were analyzed for the stance factor (SF) as well as several other aspects of the rats walking pattern. Walking was evaluated between 10 and 21 weeks after the operation. Differences in walking behavior between rats raised in an enriched environment and rats raised in standard cages could not be demonstrated. Differences in walking behavior between male and female rats were not found either. But data differed significantly at all ages with rats of the control group. Automutilation of parts of the denervated foot revealed a significant difference in both experimental groups, occurring less often in the enriched environment group.

Sir Charles Alfred Ballance (1856-1936) and the introduction of facial nerve crossover anastomosis in 1895

Sir Charles Ballance (1856-1936) was the first surgeon in history to perform a facial nerve crossover anastomosis in 1895. Although, recently, several papers on the history of facial nerve surgery have been published, little is known about this historically important operation, the theoretical reasoning behind the operation or the surgical perspective in which Ballance developed this method. An original document on the operation, dated in 1895, is not known. The earliest report of the operation is a paper by Ballance, published in 1903. Study of this 1903 paper reveals that Ballance stopped performing the operation after his first attempt in 1895 until he resumed in December 1901. What was the reason for this interruption? Why did Ballance start doing it again in 1901? Between 1895 and Ballances 1903 paper, several other surgeons had published the results of their facial nerve crossovers. Were they inspired by Ballances operation from 1895 to do the same or did they invent the method independently? To enhance our knowledge about the early history of facial nerve surgery, the original manuscripts by Ballance and his contemporaries have been studied. Ballances first facial nerve crossover from 1895 is described in the surgical perspective of the end of the 19th century. The theoretical reasoning for the operation is discussed. It was discovered that Ballances operation was first recorded in St. Thomass Hospital Report of 1895, which was published in 1897. However, this report was probably hardly known by Ballances contemporaries and consequently could not have stimulated them to perform the operation themselves. Jean Louis Faure (1863-1944), from France, appears to have been the first to have performed the operation until Ballances 1903 paper was published. In 1903, after Ballances paper had been published, many other accounts of this method were reported in the literature. At that moment facial nerve crossover seems to have been widely regarded as a potential successful technique, a technique which, a century later, is still part of our repertoire.

On the surgical treatment of facial paralysis in the early nineteenth century

Summary: The treatment of facial paralysis is generally considered to have been nonsurgical until the end of the nineteenth century. However, the authors discovered recently that already in the 1840s the celebrated German facial reconstructive surgeons Dieffenbach and von Langenbeck applied the technique of subcutaneous myotomy to healthy facial muscles to reestablish balance in the chronically paralyzed faces of their patients. They performed their operations at a time when anesthesia, asepsis, antisepsis, and antibiotics had not yet been introduced into surgery. It is concluded that Dieffenbach and von Langenbeck were the first, in recorded history, to develop a surgical way to treat irreversible facial paralysis. As their principles are still being used in surgical practice, they cannot be regarded as antiquated, which illustrates the difficulties that reconstructive surgeons still experience in the treatment of irreversible facial paralysis.

Bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas

Abstract Macrodystrophia lipomatosa is a rare disease that causes congenital local gigantism of part of an extremity, which is characterised by an increase in all mesenchymal elements, particularly fibroadipose tissue. This is the first report to our knowledge of a case of histologically confirmed bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas.

Sound-induced facial synkinesis following facial nerve paralysis

Facial synkinesis (or synkinesia) (FS) occurs frequently after paresis or paralysis of the facial nerve and is in most cases due to aberrant regeneration of (branches of) the facial nerve. Patients suffer from inappropriate and involuntary synchronous facial muscle contractions. Here we describe two cases of sound-induced facial synkinesis (SFS) after facial nerve injury. As far as we know, this phenomenon has not been described in the English literature before. Patient A presented with right hemifacial palsy after lesion of the facial nerve due to skull base fracture. He reported involuntary muscle activity at the right corner of the mouth, specifically on hearing ringing keys. Patient B suffered from left hemifacial palsy following otitis media and developed involuntary muscle contraction in the facial musculature specifically on hearing clapping hands or a trumpet sound. Both patients were evaluated by means of video, audio and EMG analysis. Possible mechanisms in the pathophysiology of SFS are postulated and therapeutic options are discussed.

Necrotizing fasciitis in the head and neck region: a case report

Necrotizing fasciitis is a potentially lethal disease. It starts as an infection of muscle fascia and soft tissue. The head and neck region is rarely involved. Spreading of the disease is very rapid and can lead to serious complications. This paper reports a patient with necrotizing fasciitis of the right upper eyelid which required debridement and intensive care admission.