Noriyuki Kuwata

Double free-muscle transfer to restore prehension following complete brachial plexus avulsion

Restoration of finger flexion and extension as well as elbow flexion and extension with a double free-muscle and multiple nerve transfers following complete avulsion of the brachial plexus (nerve roots C5 to T1) is reported. The procedure combines (1) free-muscle transfer with reinnervation by the spinal accessory nerve to achieve elbow flexion and finger extension, (2) free-muscle transfer with reinnervation by the fifth and sixth intercostal nerves to restore finger flexion, (3) third and fourth intercostal motor nerve transfer to the triceps brachi to extend and stabilize the elbow, (4) nerve transfer of the supraclavicular nerve or nerve transfer of the sensory rami of the intercostal nerves to the median nerve to restore hand sensibility, and (5) glenohumeral arthrodesis. Seven of 10 patients recovered elbow function and finger flexion and extension. Five patients reported use of their hand in activities of daily living.

Reconstruction of finger and elbow function after complete avulsion of the brachial plexus

Simultaneous reconstruction of elbow and finger function with free muscle and nerve transfers after complete avulsion of the brachial plexus (nerve roots C5 to T1) and its long-term results are presented. The basic procedure combined free or vascular pedicle latissimus dorsi muscle transfer with reinnervation by the spinal accessory nerve to obtain elbow and finger flexion, intercostal nerve transfer of the radial nerve to activate elbow and wrist extensors, and suture of the supraclavicular nerve or intercostal sensory rami to the median nerve to restore hand sensibility. Six patients had some or all of these procedures. Postoperative follow-up ranged from 2 to 5 years. Elbow function was restored completely, and some finger flexion was achieved in all cases, although a dynamic splint was necessary to straighten the digits. Patients have continued to improve in grasp power and finger control. This procedure appears to be promising for the restoration of basic hand function in severely handicapped patients.

A comparison of vascularized and conventional sural nerve grafts

Long-term results of a randomized series of 27 vascularized and 22 conventional sural nerve grafts in patients with comparable upper extremity injuries are reported. Recovery speed and outcome depended on (1) whether or not there was an overlying skin defect, (2) how the defect was closed, and (3) which nerve was injured and at what level. Generally, a vascularized nerve graft is indicated when the nerve gap is more than 6 cm and is associated with a massive skin defect or the graft is performed after reimplantation. Otherwise, results achieved with a conventional graft are equally good.

Limb-sparing surgery with reinnervated free-muscle transfer following radical excision of soft-tissue sarcoma in the extremity.

Limb-sparing surgery is the preferred approach in the management of patients with high-grade soft-tissue sarcomas when local disease can be completely resected. However, conventional treatment focuses only on restoration of basic functions to the remnant limb. Lost functions are not restored to normal, leaving the patient with variable degrees of functional disabilities. This in turn may necessitate further massive reconstructive procedures. Transferred reinnervated free muscles were used to reconstruct functions lost after radical resection of malignant soft-tissue sarcoma of the extremities in 17 patients. The long-term functional outcome included survival of transplanted muscle, speed of neural recovery, and muscle strength and disabilities. All muscles survived. Postoperative follow-up ranged from 27 to 106 months. All muscles except those in a 75-year-old patient were successfully reinnervated. Powerful strength and almost normal limb functions were obtained. Functional scoring of the patients according to the rating system of the Musculoskeletal Tumor Society was 87 percent for the lower extremity and 93 percent for the upper extremity. All patients are presently disease-free. Use of the reinnervated free-muscle transfer in limb-sparing surgery after resection of soft-tissue sarcoma in the extremity may be indicated in the young adult when radical excision of the tumor will result in severe motor functional loss, provided adequate clearance can be obtained and that there is no presence of distant metastasis.

Restoration of sensibility in the hand after complete brachial plexus injury

Twenty-one patients with complete brachial plexus palsy due to the avulsion of multiple cervical nerve roots underwent motor and sensory reconstruction. Of these, 15 patients who had been followed for at least 2 years were included in the present study. Sensory reconstruction was performed by nerve graft or nerve crossing to the median nerve. The donor nerves included the supraclavicular nerve in 10 patients, the intercostal nerve in 3, and the C5 nerve root in the first 2 patients. Limited sensibility in the median nerve distribution of the hand was restored in 12 patients, and the results were classified as S2+ in 2, S2 in 4, S1 in 6, and S0 in 3, according to the S0 to S4 grading system. No moving two-point discrimination was restored in any case. While the best recovery obtained was only at the S2+ level, even this limited sensibility was useful for otherwise completely anesthetic patients.

Alumina ceramic finger implants: A preliminary biomaterial and clinical evaluation

An alumina ceramic hinge-type finger prosthesis, composed of alumina ceramics and high-density polyethylene, is described. Biomaterial evaluations, including flexion-extension tolerance, stretching, twisting, extraction tests, and histologic examinations of affinity for bone, demonstrated that this implant has characteristics superior to those of previous finger implants. Eighteen proximal interphalangeal joints and 13 metacarpophalangeal joints have been replaced with this alumina ceramic finger implant. Follow-up studies (12 to 31 months) have been most encouraging with satisfactory functional recovery and no fracture or dislocation of the implants.

Reconstruction of the thumb with a free wrap-around flap from the big toe and an iliac-bone graft.

Ten patients with an amputated thumb had reconstruction by a free wrap-around flap taken from the big toe, including the nail, and an iliac-bone graft as the core of the reconstruction. The long-term results showed that a better replica of the thumb was achieved. The results were quite satisfactory both cosmetically and functionally, but there were some new problems: resorption of the bone graft, bulging of the pulp, skin atrophy at the base of the thumb, and deformity of the nail in a few patients. Modifications of the flap design and of the shape of the bone graft eliminated these problems nearly entirely.

A reliable technique of free vascularized sural nerve grafting and preliminary results of clinical applications

A technique of harvesting a free vascularized sural nerve graft based on either the cutaneous branch of the peroneal artery or the muscular perforating branch of the posterior tibial artery is described. Anatomic dissections with dye injection studies confirmed the reliability of this blood supply to a 25 cm long segment of the sural nerve. The sural nerve can be sectioned into as many as four segments while safely maintaining each segments vascularity through intact fascia. A skin monitor can be elevated with the nerve to monitor vascular patency. The free vascularized sural nerve was used to reconstruct 16 nerve defects in the upper extremity. All 13 skin monitors elevated have survived. Early follow-up (range, 2 to 31 months) has shown encouraging clinical recovery. Although our preliminary results are difficult to compare with other series, this technique appears promising in clinical circumstances when interfascicular nerve grafting is indicated but the recipient bed is heavily scarred and poorly vascularized.

Vascularized Osteochondral Allografts in an Immunosuppressed Rat Model: Graft Modulation and Host Immune Tolerance

The effects of 4 weeks of cyclosporin A (7 mg/kg per day) (CyA) on the survival of vascularized osteochondral grafts between rat strains [DA (donor) and Lewis (recipient)] and the presence and significance of host immune tolerance and graft antigen modulation after cessation of immunosuppression have been examined. Isografts (n = 12) survived without apparent abnormality for 8 weeks but showed signs of wasting after longer periods; unprotected allografts (n = 5) were rejected within 2 weeks. After 4 weeks of CyA, allografts remained healthy for at least 12 weeks but then deteriorated (n = 40). Antigen modulation was examined by graft removal at various intervals after cessation of CyA and reimplantation into a naive recipient (n = 14). All were rejected rapidly. Host tolerance was examined by graft removal at various periods after cessation of CyA and reimplantation of a fresh allograft (n = 15). Some of the second grafts survived at least 4 weeks without immunosuppression. The findings indicate development of incomplete host tolerance but no antigenic modulation of the graft.

Surgical options for distal radial fractures: indications and limitations.

Abstract Distal radial fractures are common problems for the orthopedic surgeon, and various surgical treatments have been reported. However, each method has its indications, pitfalls, and limitations. It is important to select the appropriate procedure for the fracture pattern. We studied 115 consecutive patients including 45 patients with distal radial fractures treated with percutaneous pinning, 67 patients treated with external fixation, and 32 patients treated with assisted wrist arthroscopy. Percutaneous pinning was useful in extra-articular fractures and minimally comminuted intra-articular fractures, but was inadequate for patients with severe osteopenia and markedly comminuted intra-articular fractures. External fixation was indicated when intra-articular comminution was present. However, the dorsomedial fragment was often not reduced and maintained by this technique; additional pinning was needed to reduce this fragment. A dynamic-type fixator was feasible for younger patients who required early functional recovery. Arthroscopy provided accurate visualization of the wrist joint and the intra-articular fracture.