The history of microsurgery.

Microsurgery is a term used to describe the surgical techniques that require an operating microscope and the necessary specialized instrumentation, the three "Ms" of Microsurgery (microscope, microinstruments and microsutures). Over the years, the crucial factor that transformed the notion of microsurgery itself was the anastomosis of successively smaller blood vessels and nerves that have allowed transfer of tissue from one part of the body to another and re-attachment of severed parts. Currently, with obtained experience, microsurgical techniques are used by several surgical specialties such as general surgery, ophthalmology, orthopaedics, gynecology, otolaryngology, neurosurgery, oral and maxillofacial surgery, plastic surgery and more. This article highlights the most important innovations and milestones in the history of microsurgery through the ages that allowed the inauguration and establishment of microsurgical techniques in the field of surgery.

Congenital anomalies of the limbs in mythology and antiquity.

Congenital anomalies of the limbs have been observed since ancient human civilizations, capturing the imagination of ancient physicians and people. The knowledge of the era could not possibly theorize on the biologic aspects of these anomalies; however, from the very beginning of civilization the spiritual status of people attempted to find a logical explanation for the existence of such cases. The next logical step of the spiritual and religious system of the ancients was to correlate these anomalies with the Gods and to attribute them to a different level of existence in order to rationalize their existence. In these settings, the mythology and religious beliefs of ancient civilizations comprised several creatures that were related to the observed congenital anomalies in humans. The purpose of this historic review is to summarize the depiction of congenital anomalies of the limbs in mythology and antiquity, to present several mythological creatures with resemblance to humans with congenital anomalies of the limbs, to present the atmosphere of the era concerning the congenital anomalies, and to theorize on the anomaly and medical explanation upon which such creatures were depicted. Our aim is to put historic information in one place, creating a comprehensive review that the curious reader would find interesting and enjoyable.

Psychological and social consequences after reconstruction of upper extremity trauma: methods of detection and management.

Upper extremity trauma and resulting disability is a stressful event and can affect a patient's personality. Several studies have shown that this injury type has serious psychological and/or social consequences. We systematically reviewed the evidence on the consequences of disability after a complex trauma (combination of soft tissue, osseous, vascular, and nerve involvement) of the upper extremity. We tried to find out the potential crucial factors that could determine the final hand function. In addition, we considered the challenges that need to be addressed to eliminate the adverse or negative effects that arise from upper limb trauma. In the literature, there is a growing interest to study changes in patients' quality of life and return to work. Psychological morbidity is an important part of patients' perceived general health. These issues could play an important role in the final functional outcome of the therapy. An early identification and treatment of trauma-related distress in patients may prevent progression of psychological pathology and mitigate negative effects on general health status. It may be important to evaluate the amount of psychological distress when caring for patients with hand injuries.

Risk factors for and complications of distraction osteogenesis.

PURPOSE: Distraction osteogenesis is commonly used for limb deformities and reconstruction of bone defects with satisfactory outcome for the patients. However, it is associated with a risk of complications. The present study aims to assess the incidence of complications and to identify the risk factors that may predict distraction osteogenesis-related complications. MATERIALS AND METHODS: We retrospectively studied 63 patients (mean age 13.5 years; range 3-57 years) who had 74 distraction osteogenesis procedures from 2004 to 2009. A circular external fixator was used in 58 procedures, and a monolateral in 16 procedures. Fixator's time, days of treatment, lengthening percentage, bone healing index, distraction regenerate length and index, risk factors and complications were evaluated. The mean follow-up was 5 years (range 2-7 years). RESULTS: Complications occurred in 57 of the 74 procedures (77%); 70% were major complications and 30% were minor. Complications were more common in adults. Bone healing index, days of treatment and fixator's time were univariate predictors of complications. Bone healing index and adult age were the only multivariate predictors of complications. CONCLUSION: Adult age and bone healing index are the most important multivariate predictors of distraction osteogenesis-related complications. Routine follow-up after implant removal, selection of younger patients with minor risk factors and shorter fixator's time are necessary to reduce the rate of distraction osteogenesis-related complications.

Thoracic Cage Deformity Correction in Patients with Lenke Type 1 Adolescent Idiopathic Scoliosis.

Whether the thoracic cage deformity in adolescent idiopathic scoliosis (AIS) can be sufficiently treated with vertebral derotation alone, has been quite controversial. Our aim is to control the hypothesis that the rib cage deformity (RCD) may be adequately corrected when only vertebral derotation is applied. We studied retrospectively patients treated for AIS with posterior spinal fusion without costoplasty. The RCD was assessed on lateral radiographs by rib index (RI). The correction of RI after surgery was calculated. Of the 103 patients that were finally included in our study, 29 patients (22 females and 7 males; mean age, 14.5 ± 2.1 years) represented Group A (Harrington rod instrumentation - no derotation), while 74 patients (61 females and 13 males; mean age, 14.1 ± 2.4 years) were operated with either a full pedicle screw system or a hybrid construct with hooks and pedicle screws (Group B-derotation). RI was significantly corrected after surgery in both groups. RI was significantly greater in Group A after surgery. Whatsoever, the correction of RI, thereby the RCD correction, did not significantly differ among groups. In conclusion, it cannot be suggested by the present study that vertebral derotation alone can offer an absolute correction of the deformity of the thoracic cage in patients with Lenke Type 1 AIS, and it seems also that the development of RCD may not exclusively result from the spinal deformity, thus questions can be further raised regarding scoliogeny per se.

Prognostic scoring system for peripheral nerve repair in the upper extremity.

So far, predictive models with individualized estimates of prognosis for patients with peripheral nerve injuries are lacking. Our group has previously shown the prognostic value of a standardized scoring system by examining the functional outcome after acute, sharp complete laceration and repair of median and/or ulnar nerves at various levels in the forearm. In the present study, we further explore the potential mathematical model in order to devise an effective prognostic scoring system. We retrospectively collected medical record data of 73 cases with a peripheral nerve injury in the upper extremity in order to estimate which patients would return to work, and what time was necessary to return to the pre-injury work. Postoperative assessment followed the protocol described by Rosén and Lundborg. We found that return to pre-injury work can be predicted with high sensitivity (100%) and specificity (95%) using the total numerical score of the Rosén and Lundborg protocol at the third follow-up interval (TS3) as well as the difference between the TS3 and the total score at second follow-up interval (TS2). In addition, the factors age and type of injured nerve (median, ulnar, or combined) can determine the time of return to work based on a mathematical model. This prognostic protocol can be a useful tool to provide information about the functional and social prospects of the patients with these types of injuries.

Intraneural OX7-saporin for neuroma-in-continuity in a rat model.

We employed 54 rats to devise a model of neuroma-in-continuity and explore the effect of the immunotoxin OX7-saporin on the neuroma. The left common peroneal, tibial or sciatic nerves were crushed by one 10-s application of a micro-artery forceps. At 3 and 6 weeks, the nerve was cut distal to the site of nerve crush, and retrograde fluorescent labeling was done. Pressure microinjection of 2 µl of natural saline or 2 µl of the immunotoxin conjugate OX7-saporin was done at the nerve stump 2 days later. Sacrifice was done after 3 weeks. In all control and saline-injection nerve specimens, gross observation and histology showed a neuroma-in-continuity. In 19 of the 24 OX7-saporin nerve specimens, gross observation showed a narrowed area at the site of nerve crush. Histology showed inhibition of neuroma-in-continuity formation. Fluorescent microscopy showed ablation of the labeled neurons in the dorsal root ganglia corresponding to the OX7-saporin subgroups.

Adipose-Derived Stem Cells and Tacrolimus Improve Nerve Regeneration in a Rat Sciatic Nerve Defect Model.

This study compared the effect of undifferentiated adipose-derived stem cells (ADSCs) vs tacrolimus (FK506) in peripheral nerve regeneration in a rat sciatic nerve complete transection model. Forty Wistar rats were equally distributed in four groups. In the SHAM surgery group, the sciatic nerve was exposed and no further intervention was done. In the conduit-alone group (the SLN group), a 10-mm nerve gap was created and bridged with a fibrin conduit filled in with normal saline. In the FK506 group, the fibrin conduit was injected with soluble FK506. In the ADSC group, the conduit was impregnated with undifferentiated ADSCs. Nerve regeneration was assessed by means of walking track analysis, electromyography, and neurohistomorphometry. Clinically and microscopically, nerve regeneration was achieved in all groups at 12 weeks. Walking track analysis confirmed functional recovery in the FK506 and ADSC groups, but there was no difference between them. Recovery in function was also achieved in the SLN group, but it was inferior (P<.05). Electromyography demonstrated superior nerve regeneration in the FK506 and ADSC groups compared with the SLN group (P<.05), with no difference between the FK506 and ADSC groups. Similarly, histology showed no difference between the FK506 and ADSC groups, although both outperformed the SLN group (P<.05). No complications were observed. Successful peripheral nerve regeneration can be accomplished after a 10-mm nerve defect treated with nerve conduits. Superior nerve regeneration may be expected when the conduits are loaded with undifferentiated ADSCs or FK506, with similar outcomes for ADSCs and FK506. [Orthopedics. 2023;46(6):e353-e361.].

Orthopedics and biofilm--what do we know? A review.

Bacteria have been found to grow predominantly in biofilms. The initial stage includes the attachment of bacteria to the substratum. Bacterial growth and division then leads to the colonization of the surrounding area and the formation of the biofilm. The environment in a biofilm is not homogeneous; the bacteria in a multispecies biofilm are not randomly distributed, but rather are organized to best meet their needs. Although there is an initial understanding on the mechanisms of biofilm-associated antimicrobial resistance, this topic is still under investigation. A variety of approaches are being explored to overcome biofilm-associated antimicrobial resistance. A greater understanding of biofilm processes should lead to novel, effective control strategies for biofilm control and a resulting improvement in patient management.

Traumatic hand amputations among children in Greece: epidemiology and prevention potential.

BACKGROUND: Traumatic hand and finger amputations frequently lead to permanent disability. OBJECTIVE: To investigate their epidemiological characteristics and estimate the prevention potential among children 0-14 years old, through a cross-sectional survey. METHODS: Nationwide extrapolations were produced based on data recorded between 1996 and 2004 in the Greek Emergency Department Injury Surveillance System and existing sample weights. Incident and injury related characteristics were analysed to identify preventable causes. RESULTS: Among 197,417 paediatric injuries, 28,225(14%) involved the hand and fingers resulting in 236 amputations (∼1% of hand injuries). The annual probability to seek emergency department care for a hand injury was 3%. The estimated incidence rate (IR) of hand amputations was 19.7/100,000 person-years. Over 50% concerned children 0-4 years old (male:female=2:1), peaking at 12-24 months. Male preschoolers suffered the highest IR (38.7/100,000). Migrant children were overrepresented among amputees. Of all amputations, 64% occurred in the house/garden and 14% in day-care/school/sports activities, usually between 08:00 and 16:00 (61%). Doors were the product most commonly involved (55% overall; 72% in day-care/school/gym) followed by furniture/appliances (15%) and machinery/tools (7%). Crushing was the commonest mechanism. Inadequate supervision and preventive measures were also frequently reported. 5% of the amputees were referred to specialised units for replantation/reconstructive surgery. CONCLUSIONS: The majority of paediatric hand and finger amputations could be prevented in Greece, particularly among preschoolers, by a single product modification, namely door closure systems, coupled with improved supervision. Paediatricians should incorporate this advice into their routine child-safety counselling. This country-specific profile supports the need for maintaining similar databases as an indispensable tool for assisting decision-making and preventing disabling and costly injuries.

Outcome models in peripheral nerve repair: time for a reappraisal or for a novel?

Peripheral nerve injuries are still underestimated. The complexity of assessment of outcome after nerve injury and repair has been described by many authors. Furthermore, the outcome is influenced by several factors that depend on mechanisms in the peripheral as well as the central nervous system. Appropriate formulation of a global accepted postoperative clinical protocol for peripheral nerve repair in the upper extremity remains a subject of debate. The purpose of this review is to detail the current concepts of methods of evaluation after peripheral nerves repair. Finally, we discuss the most crucial factors that determine the final hand function and we consider the challenges that need to be addressed to create a realistic clinical protocol that reflects a prognostic importance.

Results of extra-articular subtalar arthrodesis in children with cerebral palsy.

BACKGROUND: Grice-Green extra-articular subtalar arthrodesis is considered to be a valid surgical method which improves foot alignment in patients with spastic pes planovalgus deformity. The purpose of the present study was to examine the long-term results of Grice-Green procedure and whether it can achieve significant correction of each of the components of pes planovalgus deformity. METHODS: Eleven children (16 feet) with cerebral palsy who underwent Grice extra-articular subtalar arthrodesis were reviewed retrospectively. The mean age of patients at the time of surgery was 9 years and 8 months (range, 6 years 5 months to 12 years 4 months). The mean followup was 3 years and 7 months (range, 2 years 1 month to 8 years 3 months). Seven radiographic parameters of each patient before surgery, after surgery and at the latest followup were used. In addition, position of the graft relative to the weightbearing axis of the tibia was evaluated. RESULTS: Most of the examined parameters showed statistically significant correction which was maintained in the long run. Moreover, the placement of the graft along the mechanical axis seemed to play an important role for stability and preservation of correction of the planovalgus deformity. On the other hand, there were three cases where the osseous graft was absorbed and two cases where triple arthrodesis was necessary due to recurrence of the deformity. CONCLUSION: Grice-Green extra-articular subtalar arthrodesis improves foot alignment in patients with spastic pes planovalgus deformity and can achieve significant correction, postoperatively as well as on a long-term basis, of each of the components of pes planovalgus deformity.

Tissue-engineered vascularized bone grafts: basic science and clinical relevance to trauma and reconstructive microsurgery.

Bone grafts are an important part of orthopaedic surgeon's armamentarium. Despite well-established bone-grafting techniques, large bone defects still represent a challenge. Efforts have therefore been made to develop osteoconductive, osteoinductive, and osteogenic bone-replacement systems. The long-term clinical goal in bone tissue engineering is to reconstruct bony tissue in an anatomically functional three-dimensional morphology. Current bone tissue engineering strategies take into account that bone is known for its ability to regenerate following injury, and for its intrinsic capability to re-establish a complex hierarchical structure during regeneration. Although the tissue engineering of bone for the reconstruction of small to moderate sized bone defects technically feasible, the reconstruction of large defects remains a daunting challenge. The essential steps towards optimized clinical application of tissue-engineered bone are dependent upon recent advances in the area of neovascularization of the engineered construct. Despite these recent advances, however, a gap from bench to bedside remains; this may ultimately be bridged by a closer collaboration between basic scientists and reconstructive surgeons. The aim of this review is to introduce the basic principles of tissue engineering of bone, outline the relevant bone physiology, and discuss the recent concepts for the induction of vascularization in engineered bone tissue.

The free vascularized fibular graft for bridging large skeletal defects of the upper extremity.

Large skeletal defects of the upper extremity pose a serious clinical problem with potentially deleterious effects on both function and viability of the limb. Recent advances in the microsurgical techniques involved in free vascularized bone transfers for complex limb injuries have dramatically improved limb salvage and musculoskeletal reconstruction. This study evaluates the clinical and radiographic results of 18 patients who underwent reconstruction of large defects of the long bones of the upper extremity with free vascularized fibular bone grafts. Mean patient age was 27 years (7-43 years) and mean follow-up was 4 years (1-10 years). The results confirm the value of vascularized fibular grafts for bridging large bone defects in the upper extremity.

Repair of complete nerve lacerations at the forearm: an outcome study using Rosén-Lundborg protocol.

A comparison of outcomes based on a scoring system for assessments, described by Rosén and Lundborg, after sharp complete laceration of median and/or ulnar nerves at various levels in the forearm was carried out. There were 66 males (90.4%) and 7 females (9.6%), with a mean age of 31 years (range: 14-62 years). The patients were categorized into three groups according to the type of nerve injury. The median nerve was injured in 25 cases (group M, 34.3%), the ulnar in 27 (group U, 36.9%), and both the nerves in 21 (group MU, 28.8%). The demographic data of the patients and the mechanism of injury were recorded. We also examined the employment status at the time of the injury and we estimated the percentage of patients who returned to their work after trauma. In all cases, a primary epineural repair was performed. Concomitant injuries were repaired in the same setting. The mean period of time between injury and surgery was 5.3 hours (range: 2-120 hours). A rehabilitation protocol and a reeducation program were followed in all cases. The mean follow-up was 3 years (range: 2-6 years), with more distal injuries having a shorter follow-up period. The total score was 2.71 in group M (range: 0.79-2.99) and 2.63 in group U (range: 0.63-3), with no significant differences observed. There was a significant difference between these two groups and group MU (total score 2.03, range: 0.49-2.76, P = 0.02). Up to the last follow-up, 61 patients (83.5%) had returned to their previous work. The Rosén-Lundborg model can be a useful and simple tool for the evaluation of the functional outcome after nerve injury and repair temporally reflecting the processes of regeneration and reinnervation.

"Outcome of thoracolumbar compression fractures following non-operative treatment".

Axial compressive/flexion moderate forces on the anterior spinal elements may cause vertebral compression fractures (VCF), compromising the anterior column of the spine, reducing vertebral body height and leading to characteristic wedge-shaped deformity. 60% to 75% of VCFs are located in the thoracolumbar junction (T12 - L2) due to mechanical forces upon the transition from the relatively fixed thoracic to the relatively mobile lumbar spine. Compression force spinal fractures vary in literature according to the classification system in use, resulting in controversial treatment options. Type A fracture patterns of AO classification are eligible for non-operative treatment provided the posterior complex is intact and there are no neurologic complications. That includes both simple compressive and burst fractures. The aim of this study is to investigate the long-term consequences of non-operative treated compressive thoracolumbar fractures regarding posttraumatic deformity, chronic back pain, and functional status. A retrospective study of 75 patients with stable (compressive and burst type A AO) spinal fractures of the thoracolumbar spine (T12-L2) without neurological symptoms and treated non-operatively was conducted. Post traumatic regional kyphosis, Visual Analogue Scale (VAS) and the Oswestry Disability Index (ODI) were used to evaluate deformity progression, pain and alteration of the quality of life during follow up. There was no significant correlation between magnitude of posttraumatic regional kyphosis, sex, pain score and disability index. Statistically significant correlation between patients age and disability index was revealed.

Osteonecrosis of the tibial plateau: magnetic resonance imaging appearances with quantitation of lesion size and evidence of a pathogenesis of meniscal injury.

PURPOSE: To determine the magnetic resonance (MR) imaging appearances of osteonecrosis of the tibial plateau and perform quantitative analysis of the extent of the necrotic area. MATERIALS AND METHODS: Twenty-eight patients (34 knees) with osteonecrosis were retrospectively evaluated using MR imaging and other modalities where available. A computerized image analysis program that allowed quantification of the lesion size was used to obtain measurements of the extent of involvement, which were then incorporated into each stage of the disease. RESULTS: The MR imaging findings of osteonecrosis of the tibial plateau included subchondral regions of abnormal signal intensity (n = 28), a double-line sign (n = 11), and fractures (n = 9). Meniscal tears and cartilage abnormalities were disclosed in the affected knee compartment with an equal frequency (n = 17). The size of the necrotic lesion varied among different stages of the disease as follows: 6.8% to 15.7% (stage I); 6.5% to 59.3% (stage II); 23.5% to 61.3% (stage III); and 34.3% to 75% (stage IV). The extent of involvement was greater in stage II than that in stage I (P < 0.001) and in stage IV than that in stage III (P < 0.05), whereas the extent of involvement in stage III was not significantly greater than that in stage II (P > 0.05). CONCLUSIONS: The MR imaging characteristics of osteonecrosis of the tibial plateau are variable. The association of osteonecrosis at this site with meniscal tears and cartilage abnormalities has important implications for pathogenesis of the disease as it relates to physical stress. Quantification of the lesion size provides precise information for optimal staging of the disease.

Intrinsic passive stiffness of 2 constructs of varus proximal femoral osteotomy: external fixator or blade plate.

BACKGROUND: Despite the published clinical evidence of the implementation of external fixation of proximal femoral osteotomies, there is lack of specific laboratory justification. METHODS: Two groups of 5 adult composite femur constructs of varus proximal femoral osteotomy were tested under incremental and cyclical loading of up to 600N along the mechanical axis. Five were fixed with a blade plate and another 5 with a monolateral external fixator. Load versus displacement curves were produced, and passive stiffness of all constructs was calculated. The described loading regime aimed to simulate the initial postoperative state and provide data for the assessment of vertical intrinsic passive stiffness in partial weight-bearing conditions. RESULTS: Although the blade plate constructs showed higher average stiffness, this was not statistically significant [F(1,8)=1.712, P=0.23]. No construct failed. No failure or plastic deformation was observed under the described loading regime. CONCLUSIONS: Vertical intrinsic passive stiffness in partial weight-bearing conditions during the initial postoperative period can be considered satisfactory subsequent to unilateral external fixation of a varus intertrochanteric osteotomy. CLINICAL RELEVANCE: The results support the hypothesis that external fixation is a biomechanically sound alternative to internal fixation of varus intertrochanteric osteotomies, in selected patients.

Neuroanatomy of the brachial plexus: normal and variant anatomy of its formation.

The brachial plexus is the complex network of nerves, extending from the neck to the axilla, which supplies motor, sensory, and sympathetic fibers to the upper extremity. Typically, it is formed by the union of the ventral primary rami of the spinal nerves, C5-C8 & T1, the so-called "roots" of the brachial plexus. By examining the neural architecture of the brachial plexus, the most constant arrangement of nerve fibers can be delineated, and the most predominate variations in the neural architecture defined. A thorough understanding of the neuroanatomy of the brachial plexus, with an appreciation of the possible anatomic variations that may occur is necessary for effective clinical practice.