Free vascularized fibular grafting-25 years' experience: tips, techniques, and pearls.

Thirty years after its introduction vascularized fibula transfer remains an important tool for all surgeons dealing with particularly challenging bone reconstruction problems. It should be a consideration when simpler approaches either have failed or are expected to fail. It is particularly indicated for the reconstruction of massive bone defects associated with sepsis and bony non-unions associated with radionecrosis. The successful execution of vascularized fibular grafting, however, requires microvascular expertise and adherence to sound orthopedic principles for bone healing, including stable internal fixation, maximal bone-to-bone coaptation, and appropriate postoperative management regarding joint mobilization and weight bearing.

Massive bone defects of the upper limb: reconstruction by vascularized bone transfer.

Vascularized bone transfer is increasingly recognized as a very useful and versatile technique for reconstructing massive bone defects in the upper limb or in patients with especially challenging conditions, such as infected nonunions and nonunions associated with radionecrosis of bone. It is especially indicated for the humerus and shoulder region with more selected applications in the forearm or wrist. Although technically challenging, the outcomes of this procedure justify consideration along with alternative methods for major reconstructions of the upper limb.

Principles and process in the development of the Mayo Clinic's individual and institutional conflict of interest policy.

In 1995, federal regulations required all academic medical centers to implement policies to manage individual financial conflict of interest. At the Mayo Clinic, all staff are salaried, and all medically related intellectual property from the staff belongs to the clinic. Hence, it was necessary to develop a policy for institutional conflict of interest to complement the policy for individual conflicts of interest. This article addresses the principles and process that led to the development of the Mayo Clinic's policies that guide the management of conflict of interest of individuals and of the institution. Empowered by the Bayh-Dole Act, the Mayo Clinic participates in technology transfer through its entity Mayo Medical Ventures. Individual conflicts of interest arising from such technology transfer are associated with Institutional conflicts because all individual intellectual property belongs to the institution, per clinic policy. This policy addresses conflicts of interest that arise in research, leadership, clinical practice, investments, and purchasing. Associated with the statutory annual disclosure on personal consulting and other relationships with Industry, which are guided by federal regulations, all research protocols or grant applications require financial disclosure on initial submission and in annual progress reports. The clinic's Conflict of Interest Review Board was established to review each disclosure and recommend management of individual and institutional conflicts of interest according to policy.

Task and error analysis balancing benefits over business of electronic medical records.

Task and error analysis research was performed to identify: a) the process for healthcare organisations in managing healthcare for patients with mental illness or substance abuse; b) how the process can be enhanced and; c) if electronic medical records (EMRs) have a role in this process from a business and safety perspective. The research question is if EMRs have a role in enhancing the healthcare for patients with mental illness or substance abuse. A discussion on the business of EMRs is addressed to understand the balancing act between the safety and business aspects of an EMR.

Heterotopic nerve transfers: recent trends with expanding indication.

There has been increasing enthusiasm for heterotopic nerve transfers for brachial plexus palsy as well as peripheral mononeural dysfunction. The concept of nerve transfer surgery is not new; the first publications on the topic date back to the early 1900s. A wide variety of potential donor nerves are available including the intercostal nerves, the spinal accessory nerve, the phrenic nerve, the ipsilateral medial pectoral nerve, partial ulnar nerve, partial median nerve, thoracodorsal nerve, radial nerve to the triceps, and the ipsilateral C7 or the contralateral C7 nerve roots. Treatment strategies include avoidance of interposed nerve grafting, isolated motor recipient nerve, early transfer, neurorrhaphy close to target motor end plates, and similar diameter between donor nerve and recipient nerves.

Pectoralis major transfer for serratus anterior paralysis.

Serratus anterior paralysis can result in winging of the scapula and weakness of arm elevation. The etiology of the condition is injury to the long thoracic nerve. There are many proposed causes of long thoracic nerve injury including acute trauma, Parsonage-Turner syndrome, or viral illness. The long length of the long thoracic nerve makes it prone to compression injury along the chest wall. Most patients recover nerve function with conservative treatment. In those in whom nerve function fails to recover, surgical treatment involving pectoralis major transfer may be beneficial. In this study 9 patients underwent pectoralis major transfer with a fascia lata extension graft. The symptoms of most were improved, with correction of the winging and improved movement in the affected shoulder.

Revascularization of nerve grafts: a qualitative and quantitative study of the soft-tissue bed contributions to blood flow in canine nerve grafts.

Blood flow to canine saphenous nerve grafts either in contact with a healthy soft-tissue bed or isolated from the soft-tissue bed by entubulation was quantitated at 3, 7, 14, and 28 days after surgery with radionuclide-labeled microspheres and evaluated histomorphometrically. At 3 days there was no statistical difference between the 2 techniques in regard to nerve graft blood flow, and neither group had blood flow in the middle portion of the graft. In contrast, analysis at 7, 14, and 28 days found blood flow in the middle segments of the nonisolated conventional nerve grafts to exceed that of entubulated nerve grafts with evidence in these segments of both lateral and longitudinal revascularization. The results of this investigation support an important role for the soft-tissue bed in nerve graft revascularization and suggest that neovascularization from the soft-tissue bed is the primary mechanism for restoration of blood flow in such grafts.