Saranatra Waikakul

Results of 1018 digital replantations in 552 patients

To find out the influencing factors of the immediate and late outcome of replantation and revascularization of the digits the study was carried out as a prospective survey research during 1983 to 1995 with at least 2 year follow up. Traumatic total or subtotal amputation with inadequate circulation of the digits distal to the metacarpal head were included in the study. There were 552 patients with 366 males (675 digits) and 186 females (343 digits). Successful operation was found in 508 patients (92%) with 946 digits (92.9%). Type of injury was the most important factor influencing immediate and late outcome. Regular cigarette smoking resulted in poor immediate survival rate. Prolonged ischaemia had a significant influence in final functional outcome. Using composite skin and subcutaneous vein graft gave good survival rate. Injury at the no mans land area resulted in poor range of movement of the digit. Connecting the profundus tendon stump of the proximal part to the superficialis tendon of the amputated part gave a better result than 2 tendon repair and repairing only the profundus tendon. Replantation should be carried out even if only one digit is involved. At the 2 year follow up 195 patients (38%) were classified in grade I of Chen et al., functional outcome, while 153 (31%) were in grade II, 124 (24%) were in grade III and 36 (7%) were in grade IV.

Revascularization of degloving injuries of the limbs

Between 1990 and 1994 a study was carried out of 32 patients who had degloving injuries of the limbs. There were three types of injuries: type I, nine patients with severely damaged skin and subcutaneous tissue; type II, 13 patients whose skin and subcutaneous tissue were moderately damaged, but subcutaneous veins were still identifiable; and type III, 10 patients whose skin and subcutaneous tissue were moderately damaged and venous back flow was observed. The patients in type I were treated by extensive debridement and the flaps were used for free full and split thickness skin grafting. In type II, arterialization of the venous system of the flaps was performed and successful perfusion was observed in nine patients. In type III, venous anastomoses were performed and all had good results. Revascularization of the flaps in types II and III degloving injuries of the limbs gave good results. The raw surface which needed skin grafting was minimized and the course of treatment and morbidity were decreased.

Serum 25-hydroxy-calciferol level and failed back surgery syndrome

Purpose. To assess the association of serum 25-hydroxy-calciferol levels with pain and low back function in patients with failed back surgery syndrome. Methods. Records of 6 men and 3 women aged 25 to 54 (mean, 39.2) years who had failed back surgery syndrome after pedicular screw and rod instrumentation for lower lumbar degenerative diseases were reviewed. They had moderate-to-severe pain (visual analogue scale [VAS] score of >6) and low back function disability (Japanese Orthopaedic Association [JOA] back score of <10). In all patients, the serum 25-hydroxy-calciferol level was <30 ng/ml, indicating vitamin D deficiency. Vitamin D2 (20 000 IU per day) was given for 10 days, and vitamin D3 (600 IU per day) was given for maintenance. Patients were followed up at months 3 and 6. Three men and 4 women aged 27 to 55 (mean, 41.3) years who were age- and disease-matched but achieved good outcomes (VAS score of 0–1 and mean JOA low back score of 14.7) were used as indirect referents. All 7 matched patients except one had a normal serum 25-hydroxy-calciferol level (mean, 40.6 ng/ml). Results. In the 9 patients with failed back surgery syndrome, the mean duration of chronic pain was 2.6 years; the mean VAS score for pain was 7.7; the mean JOA low back score was 7.6; the mean number of reoperations was 2.2; and the mean serum 25-hydroxy-calciferol level was 17.0 ng/ml. Two male patients had grade-IV motor weakness and decreased sensory function based on the pin prick test. One patient had a history of prolonged (>3 months) antibiotic use after primary surgery, but had no evidence of infection. Six months after vitamin D2 and vitamin D3 supplementation, the mean serum 25-hydroxy-calciferol level improved significantly (17.0 vs. 42.5 ng/ml), as did the mean pain score (7.7 vs. 4.2) and mean JOA back score (7.6 vs. 11.1). Seven of the patients had a pain score of <6 and a JOA back score of >10, the remaining 2 patients had neurological deficits and only slight improvement. Conclusion. Vitamin D supplementation may be used as an adjuvant treatment for patients with failed back surgery syndrome.

Periacetabular limb salvage for malignant bone tumours

Purpose. To evaluate treatment outcomes in primary malignant periacetabular bone tumour removal and limb salvage with or without bone-graft reconstruction. Methods. A total of 13 patients were treated for malignant periacetabular bone tumours at Siriraj Hospital, Bangkok, Thailand. The diagnoses were chondrosarcoma (n=8), Ewings sarcoma (n=2), osteosarcoma (n=1), well-differentiated osteosarcoma (n=1), and malignant giant cell tumour (n=1). 11 patients did not undergo reconstruction following tumour resection; 2 patients received fibular bone grafts bridging the periacetabulum to the remaining sacrum. Adjuvant chemotherapy was administered for high-grade malignant tumours, and postoperative radiation therapy was performed on patients with a closed surgical margin. Results. At a mean follow-up of 24.3 months (range, 8.9–43.9 months), 9 patients remained disease-free, 3 had died of the disease, and one was alive with disease. According to the Musculoskeletal Tumor Society classification system, the mean functional analysis at final follow-up was 68.7%. Patients who underwent internal hemipelvectomy experienced a subsequent leg-length discrepancy ranging from 3 to 10 cm. Four patients had complications (one each for deep wound infection, skin necrosis, seroma, and vascular spasms) and were successfully treated with multiple debridements and appropriate antibiotics. Three patients had local recurrences; one required a classic hemipelvectomy. Conclusion. Malignant periacetabular tumours are difficult to manage. Functional results of our patients with no reconstruction or with bone-graft bridging were fair. Patients undergoing internal hemipelvectomy may experience leg-length discrepancies, which can be balanced with shoe lifts.

Vascular injuries in compound fractures of the leg with initially adequate circulation

We carried out a randomised, controlled trial in 157 patients who had isolated severe Gustilo type-IIIa and type-IIIb fractures of the metaphysis or diaphysis of the leg to determine the prevalence of vascular injuries and the role of vascular repair. All patients had stable vital signs and clinically adequate circulation in their legs before operation. In a control group of 64 patients we performed conventional surgery with systematic debridement and primary stabilisation of the fractures. In the trial group of 93 patients the major vessels and nerves adjoining the compound fracture were routinely explored and repaired when necessary after the initial procedure. Two of the 28 control patients (7.1%) with type-IIIb compound fractures had signs of inadequate circulation after the first operation. Both had major vascular injuries which were demonstrated at a second procedure. In the trial group, major vascular injuries were found in two of 54 patients (3.7%) with type-IIIa and 11 of 39 patients (28.2%) with type-IIIb compound fractures. Compared with the control group the trial group showed improved results at both the immediate and long-term follow-up. Routine exploration and early repair of injured major vessels of the leg in severe compound fractures gave encouraging results.

An aiming device for pin fixation at the iliac crest for external fixation in unstable pelvic fracture

To improve the accuracy of pinning at the iliac crest during external fixation of the pelvic fracture, an aiming device has been designed. The device consists of 3 parts: a sleeve which accommodates a 5.0 Shanz pin, a handle and guide points. The guide points were designed to grasp the iliac crest to allow proper pin fixation. The device has undergone trials to fix Shanz pins on the iliac crests of 10 cadavers by 10 recently graduated doctors. All pins were fixed in proper position and passed into the bone between the two tables of the iliac crest without penetrating the tables. The device has so far been used in 50 patients who had unstable pelvic fractures. All pins were in the proper positions and there had been no loosening at the time the pins were removed. The use of this aiming device for pinning the iliac crest for external fixation of pelvic fracture has given encouraging results.

Anatomy of L4 to S3 nerve roots

Purpose. To study the course of L4 to S3 nerve roots and their distance with the ala of the sacrum and the sacroiliac joint. Methods. The embalmed left half pelvis of 25 male and 27 female cadavers aged 30 to 91 (mean, 68) years were studied. The ventral rami of the L4, L5, S1, S2, and S3 nerve roots were dissected along their courses from the corresponding intervertebral foramina to the lesser pelvis. The distances between each nerve root and the most anterior and inferior parts of the sacroiliac joint were measured in both coronal and sagittal planes. Results. There were 3 locations of fusion of L4 and L5 nerve roots: above, on, or below the level of the most anterior part of the sacroiliac joint. Fusion of S1 and S2 nerve roots at the most inferior part of the sacroiliac joint was encountered in 10% of pelvises. Most S1 and S2 nerve roots lay medial to the sacroiliac joint and closed to the anterior cortex of the ala of the sacrum. Conclusion. Sacral nerve roots may fuse at different levels. Most L4 to S3 nerve roots lie close to the anterior surface of the sacroiliac joint and the ala of the sacrum. To prevent nerve root injury, dissection with a sharp instrument should be avoided at such area and 5 to 7 mm medial to the sacroiliac joint.

Management of pain after brachial plexus injury: a parallel study

Abstract Introduction: The study was carried out to find out the effects of surgical management on pain after brachial plexus injury. Method: A prospective with control trial was performed in 279 patients (236 males and 43 females) who had isolated total root avulsion for brachial plexus injury accompanied by pain. The patients were allocated into 5 groups according to the time between the injury and the first visit: within 2 months in group 1 (66 patients), 2 to 4 months in group 2 (80 patients), 4 to 8 months in group 3 (51 patients) and more than 8 months in group 4 (60 patients). The patients in group 5 (22 patients) all came to us within 2 months, but did not accept any kind of surgical management. So these patients received only conservative treatment and were defined as the control group. Total root avulsion was confirmed by physical examination, electrodiagnosis and cervical myelogram in all patients. Furthermore, surgical exploration was performed in all patients of groups 1, 2, 3 and 4. Neurotiz...

Using polypropylene mesh graft for soft-tissue reconstruction in internal hemipelvectomy: a case report

We report the case of a patient with chondrosarcoma involving the right pelvis and contralateral pubic area in a 45-year-old male who underwent an extensive internal hemipelvectomy without bony reconstruction. We demonstrate the technique of using polypropylene mesh graft for soft-tissue reconstruction. Follow-up at 7.5 years showed a good oncological and functional outcome.

Effect of gamma sterilisation and deep-freezing on length and strength of fascia latae

Purpose. To compare the length and strength of fascia latae after gamma sterilisation and different durations of deep-freezing. Methods. 50 pieces of fresh porcine fascia latae were randomly divided into 5 groups. Group 1 acted as controls, which were not gamma irradiated and deep-frozen. In groups 2 to 4, fascia latae were incubated in phosphate buffer solution for 4 hours, and then gamma irradiated at 25 kGy. They were preserved at −70°C for one to 3 months, respectively. In group 5, fascia latae were preserved for 3 months, and during the whole process they were fixed on a wooden board to maintain their original length. The maximum tensile strength of each fascia lata was tested at a displacement rate of 1 cm per minute until failure. Results. The maximum tensile strength was not significantly different among groups 1 to 4, but was significantly higher in group 5. Conclusion. Gamma sterilisation and deep-freezing had no effect on the strength of fascia latae, but fixation on a board could increase strength.