Do intraoperative pyloric interventions predict the need for postoperative endoscopic interventions after minimally invasive esophagectomy?

Intraoperative pyloric procedures are often performed during esophagectomies to reduce the rates of gastric conduit dysfunction. They include pyloroplasty (PP), pyloromyotomy (PM), and pylorus botulinum toxin type-A injections (BI). Despite these procedures, patients frequently warrant further endoscopic interventions. The aim of this study is to compare intraoperative pyloric procedures and the rates of postoperative endoscopic interventions following minimally invasive esophagectomy (MIE). We identified patients who underwent MIE for esophageal carcinoma and grouped them as 'None' (no intervention), 'PP', 'PM', or 'BI' based on intraoperative pyloric procedure type. The rates of endoscopic interventions for the first six postoperative months were compared. To adjust for variability due to MIE type, the rates of >1 interventions were compared using a zero-inflated Poisson regression analysis. Significance was established at P < 0.05. There were 146 patients who underwent an MIE for esophageal cancer from 2008 to 2015; 77.4% were three-hole MIE, and 22.6% were Ivor- Lewis MIE. BI was most frequent in Ivor-Lewis patients (63.5%), while PP was most frequent (46.9%) in three-hole patients. Postoperative endoscopic interventions occurred in 38 patients (26.0%). The BI group had the highest percentage of patients requiring a postoperative intervention (n = 13, 31.7%). After adjusting for higher rates of interventions in three-hole MIE patients, the BI and None groups had the lowest rates of >1 postoperative interventions. Our data did not show superiority of any pyloric intervention in preventing endoscopic interventions. The patients who received BI to the pylorus demonstrated a trend toward a greater likelihood of having a postoperative intervention. However when adjusted for type of MIE, the BI and None groups had lower rates of subsequent multiple interventions. Further research is needed to determine if the choice of intraoperative pyloric procedure type significantly affects quality of life, morbidity, and overall prognosis in these patients.

Surgical management of infected abdominal wall mesh: an analysis using the American Hernia Society Quality Collaborative.

INTRODUCTION: Several management strategies exist for the treatment of infected abdominal mesh. Using the American Hernia Society Quality Collaborative, we examined management patterns and 30-day outcomes of infected mesh removal with concomitant incisional hernia repair. METHODS: All patients undergoing incisional hernia repair with removal of infected mesh were identified. A complete repair (CR) was defined as fascial closure with mesh; a partial repair (PR) was defined as fascial closure without mesh or no fascial closure with mesh. A two-tailed p value less than or equal to 0.05 was considered statistically significant. RESULTS: A total of 282 patients were identified: 136 patients in CR group and 146 patients in PR group. Patients had similar comorbidities but differed in wound class (class IV: 55% CR vs 83% SR, p < 0.001) and incidence of associated concomitant colorectal procedures (5% CR vs 18% SR, p = 0.015). Sublay placement was used primarily in CR (94%) compared to PR (52% inlay, 48% sublay). When comparing CR to PR, length of stay (median 6, p = 0.69), complications (40% vs 44%, p = 0.44), surgical site infections (16% vs 21%, p = 0.27), surgical site occurrence (30% vs 35%, p = 0.45), and readmission within 30 days (9% vs. 13%) were not statistically different. CONCLUSIONS: Analysis of data from a multicenter hernia registry comparing CR and PR during infected mesh removal and concurrent incisional hernia repair has not identified higher rates of short-term complications between groups in the presence of infection.

Neoadjuvant talimogene laherparepvec plus surgery versus surgery alone for resectable stage IIIB-IVM1a melanoma: a randomized, open-label, phase 2 trial.

Talimogene laherparepvec (T-VEC) is a herpes simplex virus type 1-based intralesional oncolytic immunotherapy approved for the treatment of unresectable melanoma. The present, ongoing study aimed to estimate the treatment effect of neoadjuvant T-VEC on recurrence-free survival (RFS) of patients with advanced resectable melanoma. An open-label, phase 2 trial (NCT02211131) was conducted in 150 patients with resectable stage IIIB-IVM1a melanoma who were randomized to receive T-VEC followed by surgery (arm 1, n = 76) or surgery alone (arm 2, n = 74). The primary endpoint was a 2-year RFS in the intention-to-treat population. Secondary and exploratory endpoints included overall survival (OS), pathological complete response (pCR), safety and biomarker analyses. The 2-year RFS was 29.5% in arm 1 and 16.5% in arm 2 (overall hazard ratio (HR) = 0.75, 80% confidence interval (CI) = 0.58-0.96). The 2-year OS was 88.9% for arm 1 and 77.4% for arm 2 (overall HR = 0.49, 80% CI = 0.30-0.79). The RFS and OS differences between arms persisted at 3 years. In arm 1, 17.1% achieved a pCR. Increased CD8+ density correlated with clinical outcomes in an exploratory analysis. Arm 1 adverse events were consistent with previous reports for T-VEC. The present study met its primary endpoint and estimated a 25% reduction in the risk of disease recurrence for neoadjuvant T-VEC plus surgery versus upfront surgery for patients with resectable stage IIIB-IVM1a melanoma.

Does circumferential casting prevent fracture redisplacement in reduced distal radius fractures? A retrospective multicentre study.

BACKGROUND: This study evaluates whether a circumferential cast compared to a plaster splint leads to less fracture redisplacement in reduced extra-articular distal radius fractures (DRFs). METHODS: This retrospective multicentre study was performed in four hospitals (two teaching hospitals and two academic hospitals). Adult patients with a displaced extra-articular DRF, treated with closed reduction, were included. Patients were included from a 5-year period (January 2012-January 2017). According to the hospital protocol, fractures were immobilized with a below elbow circumferential cast (CC) or a plaster splint (PS). The primary outcome concerned the difference in the occurrence of fracture redisplacement at one-week follow-up. RESULTS: A total of 500 patients were included in this study (PS n = 184, CC n = 316). At one-week follow-up, fracture redisplacement occurred in 52 patients (17%) treated with a CC compared to 53 patients (29%) treated with a PS. This difference was statistically significant (p = 0.001). CONCLUSION: This study suggests that treatment of reduced DRFs with a circumferential cast might cause less fracture redisplacement at 1-week follow-up compared to treatment with a plaster splint. Level of Evidence Level III, Retrospective study.

Power spectrum analysis of heart rate fluctuation: a quantitative probe of beat-to-beat cardiovascular control.

Power spectrum analysis of heart rate fluctuations provides a quantitative noninvasive means of assessing the functioning of the short-term cardiovascular control systems. We show that sympathetic and parasympathetic nervous activity make frequency-specific contributions to the heart rate power spectrum, and that renin-angiotensin system activity strongly modulates the amplitude of the spectral peak located at 0.04 hertz. Our data therefore provide evidence that the renin-angiotensin system plays a significant role in short-term cardiovascular control in the time scale of seconds to minutes.

Mms22p protects Saccharomyces cerevisiae from DNA damage induced by topoisomerase II.

The cleavage reaction of topoisomerase II, which creates double-stranded DNA breaks, plays a central role in both the cure and initiation of cancer. Therefore, it is important to understand the cellular processes that repair topoisomerase II-generated DNA damage. Using a genome-wide approach with Saccharomyces cerevisiae, we found that Deltamre11, Deltaxrs2, Deltarad50, Deltarad51, Deltarad52, Deltarad54, Deltarad55, Deltarad57 and Deltamms22 strains were hypersensitive to etoposide, a drug that specifically increases levels of topoisomerase II-mediated DNA breaks. These results confirm that the single-strand invasion pathway of homologous recombination is the major pathway that repairs topoisomerase II-induced DNA damage in yeast and also indicate an important role for Mms22p. Although Deltamms22 strains are sensitive to several DNA-damaging agents, little is known about the function of Mms22p. Deltamms22 cultures accumulate in G2/M, and display an abnormal cell cycle response to topoisomerase II-mediated DNA damage. MMS22 appears to function outside of the single-strand invasion pathway, but levels of etoposide-induced homologous recombination in Deltamms22 cells are lower than wild-type. MMS22 is epistatic with RTT101 and RTT107, genes that encode its protein binding partners. Finally, consistent with a role in DNA processes, Mms22p localizes to discrete nuclear foci, even in the absence of etoposide or its binding partners.

Sensitization of tumor necrosis factor alpha-resistant human melanoma by tumor-specific in vivo transfer of the gene encoding endothelial monocyte-activating polypeptide II using recombinant vaccinia virus.

Tumor necrosis factor alpha (TNF-alpha) is a proinflammatory cytokine with potent experimental antitumor activity. Its clinical use in cancer treatment is severely limited by its considerable toxicity after systemic administration, and it is currently confined to isolated limb and organ perfusion settings. In this report, we introduce a novel concept of TNF-alpha-based gene therapy using the TNF-sensitizing properties of endothelial cell monocyte-activating polypeptide II (EMAP-II). We hypothesized that transfer of the EMAP-II gene into established TNF-resistant human melanomas would render these tumors sensitive to subsequent systemic TNF-alpha treatment. To achieve tumor selective gene delivery, we constructed a recombinant vaccinia virus encoding the human EMAP-II gene (vvEMAP). In vitro transfection of human melanoma cells led to the production of EMAP-II by these cells. Supernatants of vvEMAP-transfected tumor cells mediated the induction of tissue factor in endothelial cells. We characterized the pattern of gene expression after systemic administration of a recombinant vaccinia virus encoding a reporter gene in a murine in vivo model of s.c. human melanoma. Gene expression in tumor tissue was increased 100-fold as compared with normal tissue, providing evidence for tumor-selective gene delivery. Finally, human melanomas in nude mice were sensitized in vivo by transferring the EMAP-II gene using vvEMAP. Subsequent systemic administration of TNF-alpha led to tumor regression and growth inhibition of these previously TNF-resistant tumors (P < 0.05). This approach using gene therapy to sensitize primarily unresponsive tumors toward TNF-alpha may enhance the usefulness of TNF-alpha in clinical treatment strategies by increasing the window for the therapeutic application of the cytokine, thus reducing the dose necessary for antitumor responses and subsequently reduce toxicity.

In vivo sensitivity of human melanoma to tumor necrosis factor (TNF)-alpha is determined by tumor production of the novel cytokine endothelial-monocyte activating polypeptide II (EMAPII).

Tumor necrosis factor (TNF)-alpha is a potent anticancer agent that seems to selectively target tumor-associated vasculature resulting in hemorrhagic necrosis of tumors without injury to surrounding tissues. The major limitation in the clinical use of TNF has been severe dose-limiting toxicity when administered systemically. However, when administered in isolated organ perfusion it results in regression of advanced bulky tumors. A better understanding of the mechanisms of TNF-induced antitumor effects may provide valuable information into how its clinical use in cancer treatment may be expanded. We describe here that the release of a novel tumor-derived cytokine endothelial-monocyte-activating polypeptide II (EMAPII) renders the tumor-associated vasculature sensitive to TNF. EMAPII has the unique ability to induce tissue factor production by tumor vascular endothelial cells that initiates thrombogenic cascades, which may play a role in determining tumor sensitivity to TNF. We demonstrate here that constitutive overexpression of EMAPII in a TNF-resistant human melanoma line by retroviral-mediated transfer of EMAPII cDNA renders the tumor sensitive to the effects of systemic TNF in vivo, but not in vitro. This interaction between tumors and their associated neovasculature provides an explanation for the focal effects of TNF on tumors and possibly for the variable sensitivity of tumors to bioactive agents.

Prognostic value of initial fasting serum gastrin levels in patients with Zollinger-Ellison syndrome.

PURPOSE: To assess the value of the initial fasting serum gastrin (FSG) at presentation in patients with Zollinger-Ellison Syndrome (ZES) in predicting primary tumor characteristics and survival. PATIENTS AND METHODS: A total of 239 patients were treated for ZES between December 1981 and September 1998, with a mean follow-up of 9.1 +/- 0.6 years. At initial evaluation, 86 patients (36%) had mild (0 to 499 pg/mL), 61 (25.5%) had moderate (500 to 1,000 pg/mL), and 92 (38.5%) had severe (> 1,000 pg/mL) elevations in FSG. Primary tumor location and size, presence of lymph node or hepatic metastases, and survival were analyzed based on the level of initial FSG. RESULTS: In patients with sporadic ZES, but not in those with multiple endocrine neoplasia type 1 (MEN-1) and ZES, there was a significant relationship between the level of initial FSG and tumor size and location of primary tumor, frequency of lymph node and liver metastases, and survival. The median 5- and 10-year survival decreased with increasing initial FSG (P <.001) in patients with sporadic ZES; MEN-1 patients lived longer than sporadic ZES patients (P =.012), and survival in this group was not associated with the level of initial FSG. Multivariate analysis showed that factors independently associated with death from disease in patients with sporadic ZES were liver metastases (P =.0001), a pancreatic site (P =.0027), and primary tumor size (P =.011) but not initial FSG (P >.30). CONCLUSION: The severity of FSG at presentation is associated with size and site of tumor and the presence of hepatic metastases, factors that are significant independent predictors of outcome. The level of FSG at presentation may be useful in planning the nature and extent of the initial evaluation and management in patients with sporadic ZES.

Internal fixation of unstable fracture dislocations of the proximal interphalangeal joint.

We report a group of 14 patients with fracture dislocations of the proximal interphalangeal joint with fracture fragments of adequate size to allow reduction of the proximal interphalangeal joint and internal mini screw fixation of the bone fragment attached to the palmar plate to the base of the middle phalanx. Three years after surgery, (range 25-52 months) the average total active range of motion of the proximal interphalangeal joint was 100 degrees (range 65-115 degrees) for the acute group (operation within 14 days of injury, n=7) and 86 degrees (range 60-110 degrees) for the chronic group (operation on average 46 days after injury, range 21-120 days, n=7). Longer delay from injury was associated with a decreased total range of motion (P=0.028). Further subluxation occurred in three chronic group patients, one required further surgery. The key to successful treatment of this injury is the re-establishment of joint congruity and early mobilization. With appropriate patient selection, pain free, satisfactory range of motion can be achieved. There is a risk of persistent subluxation or dislocation, particularly if treatment is delayed.

Rupture of the flexor digitorum profundus tendon to the small finger within the carpal tunnel.

We report three patients who sustained a rupture of the flexor digitorum profundus tendon to the small finger within the carpal tunnel. There was a common mechanism of injury, each rupture occurred during resisted flexion of the digit with the metacarpophalangeal joint in extension. All the patients were male, one patient had an asymptomatic undiagnosed fracture of the hook of hamate, one patient had radiological evidence of piso-triquetral osteoarthritis. In each case, an attrition rupture was confirmed at surgery.

Botulinum toxin treatment of cocontractions after birth-related brachial plexus lesions.

The authors studied botulinum toxin type A therapy of severe biceps-triceps cocontractions after nerve regeneration following birth-related brachial plexus lesions. Six children (age, 2 to 4 years) were treated two to three times over a period of 8 to 12 months with 40 mouse units of botulinum toxin at two sites of the triceps muscle. Elbow range of motion improved from 0 to 25 to 50 deg to 0 to 25 to 100 deg (p < 0.05), and muscle force of elbow flexion increased from a mean of Medical Research Council classification 1.7 to 3.7 (p < 0.05). After a 1-year follow-up, there was no clinical recurrence.

Isolated hepatic perfusion for lapine liver metastases: impact of hyperthermia on permeability of tumor neovasculature.

BACKGROUND: Hyperthermic isolated hepatic perfusion (IHP) has been shown to cause significant regression of advanced unresectable liver metastases in patients. Although there are different agents and treatment modalities used in IHP, the contribution of perfusion hyperthermia is unknown. PURPOSE: A large animal model of unresectable liver metastases and a technical standard for IHP in this model were established. This model was used to assess the effects of hyperthermia on vascular permeability of tumors and normal liver tissue during IHP. METHODS: Sixty-five New Zealand White rabbits were used in a series of experiments. Disseminated liver tumors were established by direct injection of 1 x 10(6) VX-2 cells into the portal vein by laparotomy in anesthetized animals. Several surgical perfusion techniques were explored to determine a reliable and reproducible IHP model. Vascular permeability in tumor versus liver was then assessed with Evan's Blue labeled bovine albumin under normothermic (tissue temperature 36.5 degrees C +/- 0.5 degree C), moderate hyperthermic (39 degrees C +/- 0.5 degree C), or severe hyperthermic (41 degrees C +/- 0.5 degree C) conditions. RESULTS: Tumor model and perfusion techniques were successfully established with inflow through the portal vein and outflow through an isolated segment of the inferior vena cava. A gravity driven perfusion circuit with stable perfusion parameters and complete vascular isolation was used. Vascular permeability was higher in tumor than in normal tissues (P = .03) at all time points during IHP. Hyperthermia resulted in a significant (up to 5-fold) increase in permeability of neovasculature; when severe hyperthermia was used, tumor vascular permeability was increased even more than normal liver permeability (P = .01). CONCLUSIONS: The VX-2/New Zealand White rabbit system can be used as a reproducible large-animal model for IHP of unresectable liver metastases. It can be used to characterize the contribution and mechanism of action of different treatment parameters used in IHP. Hyperthermia preferentially increases vascular permeability in tumors compared with liver tissue in a dose-dependent fashion, thus providing a mechanism for its presumed benefit during isolated organ perfusion.

The clinical implications of hypophosphatemia following major hepatic resection or cryosurgery.

OBJECTIVES: To determine the incidence and predisposing factors leading to postoperative hypophosphatemia after major hepatic surgery and the consequences of this electrolyte abnormality. DESIGN: A retrospective study. SETTING: A university tertiary care referral center. PATIENTS AND METHODS: Thirty-five consecutive patients undergoing either major hepatic resections or cryosurgery from July 1994 through January 1997 were retrospectively reviewed for the occurrence of hypophosphatemia and postoperative complications. MAIN OUTCOME MEASURES: Prolonged ventilatory support, intensive care unit and hospital stays, and the incidence of postoperative complications. RESULTS: The overall incidence of hypophosphatemia in our series was 21 (67%) of 35 with a mortality rate of 1 (2.8%) in 35. Mean operative time, estimated blood loss, partial vascular occlusion time, and transfusion requirements were similar between the hypophosphatemic and the nonhypophosphatemic groups. The presence of postoperative complications was significantly greater in the hypophosphatemic group (17 [80%] of 21) vs the nonhypophosphatemic group (4 [28%] of 14) (P<.05). The incidence of antacid use in the hypophosphatemic group (14 [66%] of 21) was significantly higher than the use in the nonhypophosphatemic group (2 [14%] of 14) (P<.05). CONCLUSIONS: Hypophosphatemia commonly occurs in major hepatic procedures. The presence of moderate hypophosphatemia is associated with the use of antacid therapy but no other perioperative or operative variables. The occurrence of hypophosphatemia correlates with an increased incidence of postoperative complications. Awareness of this entity can direct aggressive replacement of phosphates and avert the occurrence of severe hypophosphatemia and associated complications.

Heterogeneous gland size in sporadic multiple gland parathyroid hyperplasia.

BACKGROUND: The success rate for bilateral exploration in patients with primary hyperparathyroidism approaches 95%. Multiglandular parathyroid hyperplasia accounts for approximately 10% to 30% of primary hyperparathyroidism. The incidence of recurrent or persistent hyperparathyroidism is highest in familial forms of the disease, in which multiglandular disease is more common; this may be due to asymmetric enlargement of parathyroid glands. Because of improvements in tumor-imaging capability, some surgeons are now advocating unilateral exploration for primary hyperparathyroidism, but there is limited experience concerning how often these imaging methods fail. STUDY DESIGN: The outcomes of 7 patients who had sporadic primary hyperparathyroidism with multigland hyperplasia were reviewed. We gathered demographic data and laboratory values and reviewed radiologic tests, surgical findings, pathologic findings, and postoperative followup. RESULTS: All patients underwent preoperative localization with ultrasonography and technetium/sestamibi scans. The sensitivity of these two tests for the dominantly enlarged gland was 100% for both, but dropped to 0% and 5%, respectively, for all other enlarged glands. The sensitivity of CT and MRI for the dominant tumor was 67% (2 of 3) and 50% (1 of 2), respectively. Six of 7 patients underwent subtotal (3(1/2) gland) parathyroidectomy. The mean volume of all glands was 1.51+/-5.89 cm3 compared with a mean of 5.66+/-11.4 cm3 for all dominant glands and 0.123+/-0.1 cm3 for all nondominant hyperplastic glands. There was a large amount of variability between the volumes of dominant and other glands as demonstrated by large SDs from the mean. CONCLUSIONS: There is a marked heterogeneity in gland size in patients with sporadic multigland hyperplasia, which is similar to that found in multiple endocrine neoplasia type I. This heterogeneity may result in failure to recognize multigland disease if a unilateral neck exploration is performed. Intraoperative parathyroid hormone assay may prove to be an important adjunct in this population of patients who have unsuspected multigland disease.

Flap perfusion after free musculocutaneous tissue transfer: the impact of postoperative complications.

In a previous study, the authors found persistence of pedicle blood flow up to 10 years after uncomplicated free latissimus dorsi transfer. In this study, the impact of postoperative complications (hematoma, thrombosis, infection) and successful surgical revision was tested. Since 1982, more than 1200 free tissue transfers have been performed at the authors' institution (Hannover Medical School). Of these, the authors selected two groups of 30 patients each who had received a free latissimus dorsi transfer to the lower leg without microsurgical nerve coaptation for wound coverage. All patients included in this study were carefully selected for clinical homogeneity, with one difference: group I comprised patients who had no postoperative complications after free latissimus dorsi transfer. Group II included only patients with major postoperative complications after the procedure. All flaps in group II survived after successful surgical revision. The arteries, which nourished the lower leg, were visualized and documented by means of a duplex scanner in both groups. Three different time intervals were chosen for measurements of blood flow: 4 to 6 months (groups I.I and II.I), 4 to 6 years (groups I.II and II.II), and 8 to 10 years (groups I.III and II.III). Quantitative measurements of local flap perfusion in milliliters per minute per 100 g tissue were performed by means of the hydrogen clearance technique. In each patient, a total of nine measurements was performed in three phases: phase A, before closing the vascular pedicle by manual compression (n = 3); phase B, with a closed pedicle (n = 3); and phase C, after releasing the vascular pedicle from manual compression (n = 3). Each measurement took approximately 10 minutes. One hundred percent closure of each pedicle in phase B was confirmed by the duplex scanner. Furthermore, all patients were monitored both clinically and by means of the hydrogen clearance technique during phase B for adequate blood supply to the lower leg. Lower leg perfusion showed no statistical differences for phases A, B, and C in all groups of patients. In group I, no statistical differences in local flap perfusion were encountered for phases A and C. In phase B, however, a statistically significant (p < 0.01) complete extinction of local flap perfusion was registered in all patients of group I at the site of the flap's skin paddle. In group II, however, persistent flap perfusion was registered during phase B in up to 50 percent of cases in one subgroup (II.III). No statistically significant alterations of local blood flow were registered in the surrounding tissue of group II during phases A, B, and C. Patients with thrombosis of the venous anastomosis (n = 7) seemed to have the highest incidence of loss of autonomous blood supply through the vascular pedicle (5 out of 11 cases). No inconstant results were found during the repetitive measurements (n = 3) for each patient in each phase. After uncomplicated free tissue transfer, the flap's intact vascular pedicle seems to play an important role in permanent flap survival up to 10 years after the procedure. Postoperative complications after free tissue transfer with successful surgical revision, especially venous thrombosis of the vascular anastomosis, may lead to loss of vascular flap autonomy over time.

[Gene therapy possibilities in plastic surgery]. / Gentherapeutische Möglichkeiten in der plastischen Chirurgie.

Advances in gene technologies have meanwhile reached plastic surgery. Important contributions in this field (which are not all included in the paper) come not only from plastic surgeons, but also from neighboring specialities like dermatology, trauma surgery, orthopedics and vascular surgery. The uniting principle for all this work is improving wound healing and reconstructing tissue defects taking into consideration functional and aesthetic aspects. Gene-therapy is gaining further importance in the clinical field of plastic surgery. In this regard, every clinician has to be aware of the fact that progress in experimental and experimental-clinical work will be achieved only with the help of basic science. On the other hand, basic science needs the clinical input to get relevant patient-oriented studies started. Further intensive cooperation between clinicians and basic scientists is therefore mandatory. In plastic surgery, 2 years ago we founded a forum called ECSAPS (European Conference of Scientists and Plastic Surgeons), which takes place in European city every year.

Early microsurgical treatment of obstetrical brachial plexus lesions. Patient selection and results.

A review of the literature reveals that with conventional treatment alone or in combination with secondary muscle/tendon transfer, about 4-43 % of cases show incomplete recovery with severe functional and/or aesthetic impairment (group III). If these patients undergo early microsurgical brachial plexus revision, regeneration without significant functional and/or aesthetic impairment (shift from group III to group II) can be achieved in 80-90 % of cases. Moreover, microsurgical reconstruction of the brachial plexus increases the possibilities of secondary muscle/tendon transfers. Therefore, provided patient selection is good, severe obstetrical brachial plexus injuries should be scheduled for early microsurgical revision. There is no need to wait for a frustrating spontaneous recovery. Our concept is based on our experience with more than 1100 patients presenting with brachial plexus lesions between 1981 and 1996 and treated in our institution. There were 217 obstetrical brachial plexus lesions, 133 of which were treated conservatively. In 84 cases operative treatment was necessary. Fifty-one cases underwent early revision of the brachial plexus, and secondary tendon transfer was done in 33 patients.

A vascularised bone graft from the medial femoral condyle for recurrent failed arthrodesis of the distal interphalangeal joint.

A vascularised bone graft from the medial femoral condyle was used to correct a recurrent failed arthrodesis of the index finger distal interphalangeal joint. The flap was based upon the articular branch of the descending genicular artery. Union was confirmed 3 months after surgery.