Access to surgical upper extremity care for people with tetraplegia: an international perspective.

STUDY DESIGN: Survey. OBJECTIVES: To determine whether upper extremity reconstruction in patients with tetraplegia is underutilized internationally and, if so, what are the barriers to care. SETTING: International-attendees of a meeting in Paris, France. METHODS: One hundred and seventy attendees at the Tetrahand meeting in Paris in 2010 were sent a 13-question survey to determine the access and utilization of upper limb reconstruction in tetraplegic patients in their practice. RESULTS: Respondents ranged the globe including North America, South America, Europe, Asia and Australia. Fifty-nine percent of respondents had been practicing for more than 10 years. Sixty-four percent of respondents felt that at least 25% of people with tetraplegia would be candidates for surgery. Yet the majority of respondents found that <15% of potential patients underwent upper extremity reconstruction. Throughout the world direct patient referral was the main avenue of surgeons meeting patients with peer networking a distant second. Designated as the top three barriers to this care were lack of knowledge of surgical options by patients, lack of desire for surgery and poor referral patterns to appropriate upper extremity surgeons. CONCLUSION: The results of this survey, of a worldwide audience, indicate that many of the same barriers to care exist regardless of the patient's address. This was a preliminary opinion survey and thus the results are subjective. However, these results provide a roadmap to improving access to care by improving patient education and interdisciplinary physician communication.

Surgical restoration of the upper limb in cervical spinal cord injury patients.

Prior to the 1950s, relatively few patients who suffered a transection of the cervical spinal cord survived their injury. Improved medical care and better coordination have resulted in greater numbers of patients surviving and leaving the hospital. The pioneering work of individual surgeons during the 1960s and 1970s stimulated interest in surgical restoration of upper limb function in tetraplegic patients. Since the publication of Moberg's monograph in 1978, surgical improvement of the upper limbs is regarded as one of the options that should be offered to tetraplegic individuals to improve their function. Patients are classified according to the level of spinal cord injury and the residual motor function (international classification: groups 1-9). Surgical procedures are adapted to the motor level for each group of patients. Indications for these procedures are well standardized, the techniques are well mastered, and predictable results can be expected. New nerve transfer techniques have been developed in recent years; they are currently being evaluated.

Effect of low frequency low energy pulsing electromagnetic field (PEMF) on X-ray-irradiated mice.

C3H/Km flora-defined mice were used to investigate the effect of exposure to pulsing electromagnetic field (PEMF) after total body x-ray irradiation. Prolonged exposure to PEMF had no effect on normal nonirradiated mice. When mice irradiated with different doses of x-ray (8.5 Gy, 6.8 Gy, and 6.3 Gy) were exposed to PEMF 24 h a day, we observed a more rapid decline in white blood cells (WBC) in the peripheral blood of mice exposed to PEMF at all the x-ray dosages used. No effect of exposure to PEMF was observed on the survival of the mice irradiated with 6.3 Gy and 8.5 Gy; in mice irradiated with 6.8 Gy, 2 out of 12 survived when exposed to PEMF as compared to 10 out of 12 control mice that were irradiated only. At day 4 after irradiation autoradiographic studies performed on bone marrow and spleen of 8.5-Gy-irradiated mice showed no difference between controls and mice exposed to PEMF, whereas on 6.8-Gy mice the bone marrow labeling index was lower in mice exposed to PEMF. In mice irradiated to 6.3 Gy we observed that the recovery of WBC in the peripheral blood was slowed in mice exposed to PEMF and their body weight was significantly lower than in control mice that were irradiated only. The spleen and bone marrow of the mice irradiated to 6.3 Gy and sacrificed at days 4, 14, 20, and 25 after irradiation were analyzed by autoradiography to evaluate the labeling index. Half of the spleens from mice sacrificed at day 25 after irradiation were used to evaluate the RNA content. Autoradiography showed that in the spleen and bone marrow of control mice, there were more cells labeled with [3H]thymidine at days 4 and 14 and less at days 20 and 25 after irradiation in comparison with mice irradiated and exposed to PEMF. The Northern blot analysis of histone H3 and p53 protein RNAs extracted from the spleens at day 25 after irradiation showed a slight increase in cycling cells among spleens of mice exposed to PEMF. We suggest that the exposure to PEMF immediately after x-ray irradiation results in increased damage.

Enhancement of axon growth by detergent-extracted nerve grafts.

BACKGROUND: The immunogenicity of nerve allografts is responsible for their rejection. We have developed a method for preparing cell-free nerve grafts using lysophosphatidylcholine to remove cells, axons, and myelin sheaths. METHODS: The remaining intact nerve extracellular matrix is the extracted nerve graft (eNG). Cultured neonatal Schwann cells were micro-injected into the eNG to form recellularized nerve grafts (rNG). eNG, rNG, and normal isografts (15 mm long) were implanted in the peroneal nerves of F-344 rats. Ten rats were given an eNG on the right, and an isograft on the left. Ten rats were given an rNG on the right, and a sham operation on the left. Sham operation was used as the control and the isograft was used as the benchmark procedure. Walking track analysis was performed every 15 days after surgery to determine the peroneal functional index. Morphometric analysis of the distal peroneal nerve and extensor digitorum muscle weight were analyzed 3 months after surgery. RESULTS: The three types of grafted legs had the classical effect observed after peripheral nerve repair, with decreased functional ability, decreased target muscle weight, fewer large nerve fibers, and more small nerve fibers. Isografts, eNG, and rNG all had similar patterns of peroneal functional index improvement after implantation. The extensor digitorum longus muscle weight and axon counts for the three types of graft were not statistically different. Hence, eNG and rNG can enhance nerve regeneration in the same way as isografts. The host Schwann cells that invaded the implanted eNG probably acted in the same fashion as the cultured Schwann cells injected into the rNG and the resident cells of isografts. CONCLUSIONS: The great permeability of the longitudinally oriented matrix of eNG to cells is, therefore, a major advantage over the reported poor permeability of freeze-thawed nerve grafts.

Improvement of Schwann cell attachment and proliferation on modified hyaluronic acid strands by polylysine.

Hyaluronic acid (HyA) has the intrinsic ability to promote cell proliferation and reduce scar formation. However, the clinical use of HyA has so far been limited because of its water solubility and nonadhesive characteristics. Increasing interest in HyA as a clinically useful biomaterial has prompted our study of altering HyA's physical properties to render it a potential component of nerve grafts. In this study, strands of HyA were cross-linked by glutaraldehyde (Glut), coated with polylysine, and then inoculated with Schwann cells (SCs). Results in vivo and in vitro demonstrated that cross-linked HyA strands were water insoluble and thus less biodegradable. Poly-D-lysine-resurfaced strands showed significant SC attachment of 350-400 cells/mm(2), compared to uncoated controls (0-10 cells/mm(2), p < 0.01). Fibroblast control groups showed an attachment of 40-100 cells/mm(2) on coated strands. Immunostaining for proliferating cells showed SCs as and fibroblasts as +. Cells neither adhered to nor proliferated on the modified HyA strands that were not resurfaced. The results suggest that polylysine promotes SC attachment and proliferation to glutaraldehyde-cross-linked HyA strands, the product being a three-dimensional composite with low solubility that may have potential application in nerve grafts.

Preliminary experiments in nerve regeneration through laser-drilled holes in silicon chips.

Many of the present limitations of peripheral nerve repair might be overcome by performing nerve repairs at the axon level. One approach to nerve repair at this level would be to implant a neuroprosthesis in the form of a microelectronic switchboard which could route the connections of regenerated axons to their correct destinations. This requires a merger of microsurgery and microelectronics. Three steps are needed to achieve this goal. (1) The achievement of in vivo compatibility and electrical contact between axons and a material compatible with microelectronics. (2) The fabrication of a microelectronic neuroprosthesis with electrodes to establish communication with the axon. (3) The development of signal processing hardware and software to control the mapping of the regenerated axons. This report describes preliminary experiments in regenerating peripheral nerve axons through an electronic-grade silicon chip with laser-drilled holes small enough to capture either one or a few axons per hole. We have observed the viability of such nerves in 4 rats for 6 months to 1 year, and in two primates for more than 3 months. As our experiments show, this technique is not yet as effective as suture repair, but the development of a neuroprosthesis that communicates with peripheral nerve axons could have applications including nerve repair, neuroma, and nerve grafts, as well as interfacing the peripheral nervous system to prostheses of other kinds.

Common hand problems.

The principles illustrated in this brief survey are germane to all surgery. They cross whatever boundaries exist between specialties; in the hand, there are no divisions into parts for general, plastic, orthopedic, or neurosurgeons. They are essential to the success and parallel Boyes' description of Bunnell's influence in "the restoration of function, a careful detailed evaluation of the problem and a skillful manipulation of the parts, to accomplish the planned result. Solutions were sought and planned by thinking in broad terms of function, but the surgery is executed with maximum attention to details.

Quantification of fingertip force reduction in the forefinger following simulated paralysis of extensor and intrinsic muscles.

Objective estimates of fingertip force reduction following peripheral nerve injuries would assist clinicians in setting realistic expectations for rehabilitating strength of grasp. We quantified the reduction in fingertip force that can be biomechanically attributed to paralysis of the groups of muscles associated with low radial and ulnar palsies. We mounted 11 fresh cadaveric hands (5 right, 6 left) on a frame, placed their forefingers in a functional posture (neutral abduction, 45 degrees of flexion at the metacarpophalangeal and proximal interphalangeal joints, and 10 degrees at the distal interphalangeal joint) and pinned the distal phalanx to a six-axis dynamometer. We pulled on individual tendons with tensions up to 25% of maximal isometric force of their associated muscle and measured fingertip force and torque output. Based on these measurements, we predicted the optimal combination of tendon tensions that maximized palmar force (analogous to tip pinch force, directed perpendicularly from the midpoint of the distal phalanx, in the plane of finger flexion-extension) for three cases: non-paretic (all muscles of forefinger available), low radial palsy (extrinsic extensor muscles unavailable) and low ulnar palsy (intrinsic muscles unavailable). We then applied these combinations of tension to the cadaveric tendons and measured fingertip output. Measured palmar forces were within 2% and 5 degrees of the predicted magnitude and direction, respectively, suggesting tendon tensions superimpose linearly in spite of the complexity of the extensor mechanism. Maximal palmar forces for ulnar and radial palsies were 43 and 85% of non-paretic magnitude, respectively (p<0.05). Thus, the reduction in tip pinch strength seen clinically in low radial palsy may be partly due to loss of the biomechanical contribution of forefinger extrinsic extensor muscles to palmar force. Fingertip forces in low ulnar palsy were 9 degrees further from the desired palmar direction than the non-paretic or low radial palsy cases (p<0.05).

Action potentials of curved nerves in finite limbs.

Previous simulations of volume-conducted nerve-fiber action-potentials have modeled the limb as semi-infinite or circularly cylindrical, and the fibers as straight lines parallel to the limb surface. The geometry of actual nerves and limbs, however, can be considerably more complicated. This paper presents a general method for computing the potentials of fibers with arbitrary paths in arbitrary finite limbs. It involves computing the propagating point-source response (PPSR), which is the potential arising from a single point source (dipole or tripole) travelling along the fiber. The PPSR can be applied to fibers of different conduction velocities by simple dilation or compression. The method is illustrated for oblique and spiralling nerve fibers. Potentials from oblique fibers are shown to be different for orthodromic and antidromic propagation. Such results show that the straight-line models are not always adequate for nerves with anatomical amounts of curvature.

Congenital anomalies--looking ahead.

The management of upper limb congenital anomalies has been affected by modern techniques and technology and shaped by socioeconomic influences. Future technologic advances will have a major impact on tomorrow's diagnosis and treatment.

Management of pressure sores in a specialty center. A reappraisal.

We report a study on the surgical management of 145 pressure sores in 115 patients treated in a spinal cord injury center. There is a definite trend toward better education of these patients, who do not develop their first pressure sores until years following the injury. When the patient comes in for an ulcer, he is usually healthy and the ulcer is small and clean. In such instances the ulcer can be excised and closed, preferably with a myocutaneous flap, and the patient can usually begin sitting by the 21st post-operative day. In the ideal setting he may be discharged to his home on a custom-fitted (for pressure) cushion within 4 to 5 weeks, without increasing the risk of recurrence. Prophylaxis for the future is, probably, the most essential part of the treatment.

Repetitive trauma and nerve compression.

Repetitive movement of the upper extremity, whether recreational or occupational, may result in various neuropathies, the prototype of which is the median nerve neuropathic in the carpal canal. The pathophysiology of this process is incompletely understood but likely involves both mechanical and ischemic features. Experimentally increased pressures within the carpal canal produced reproducible progressive neuropathy. Changes in vibratory (threshold-type) sensibility appears to be more sensitive than two-point (innervation density-type) sensibility. The specific occupational etiologies of carpal neuropathy are obscured by methodologic and sociological difficulties, but clearly some occupations have high incidences of CTS. History and physical examination are usually sufficient for the diagnosis, but diagnostic assistance when required is available through electrophysiological testing, CT scanning, and possibly MRI. Each of these tests has limitations in both sensitivity and specificity. Treatment by usual conservative means should be combined with rest from possible provocative activities. Surgical release of the carpal canal is helpful in patients failing conservative therapy. Occupational modifications are important in both treatment and prevention of median neuropathy due to repetitive trauma.

The results of microneurosurgical reconstruction in complete brachial plexus palsy. Assessing outcome and predicting results.

The outcome of microsurgical reconstruction in 114 adult patients presenting with complete traumatic brachial plexus palsy was analyzed. The authors examined the effects of age, time since injury, operative findings, and the techniques of reconstruction on the level of muscle recovery. Statistical and analytic computer programs were used in an attempt to determine what factors most influenced recovery.

Changing perspectives in surgical hand rehabilitation in quadriplegic patients.

Every motivated quadriplegic patient with resources for strong wrist extension, and lacking irreversible pathological features, is a candidate for reconstruction of at least a basic strong pinch. This basic pinch is better than that obtained with a prosthesis. We feel that this possibility exists in no less than 75 percent of our quadriplegic patients.

Herpetic whitlow--a non-surgical infection of the hand.

Herpetic whitlow, or herpes simplex infection of the fingertips, is a medical illness which responds unfavorably to surgical management. If left to its own course, this angry-appearing lesion will disappear with 3 to 4 weeks-with no residual damage.

Extensor digiti minimi tendon transfer to prevent recurrent ulnar drift.

Thirty percent of patients with rheumatoid arthritis develop ulnar drift. Although numerous operations have been described, recurrence of the deformity is frequent. We recommend use of the extensor digiti minimi tendon transfer to prevent recurrent ulnar deviation. The tendon insertion is moved from a dorsal location to a dorsal-radial position. In this new location, the tendon produces both extension and radial deviation. Moreover, this transfer is maximally effective in extension when ulnar drift is greatest. We have used this transfer 28 times during the past 6 years. In evaluating patients more than 1 year after surgery, metacarpal phalangeal joint extension averaged 52 degrees and there was no evidence of recurrent ulnar drift of the little finger. The only problem was slight hyperextension of less than 5 degrees in approximately half of the patients. However, in no patient was this functionally a problem. We recommend the use of this tendon transfer in all patients with ulnar drift undergoing metacarpal phalangeal joint replacement for rheumatoid arthritis.

Use of vastus lateralis muscle flap for repair of trochanteric pressure sores.

The use of a vastus lateralis muscle flap is suggested as an approach to the surgical repair of trochanteric pressure sores in paraplegic patients. The details of the anatomy of the muscle are outlined, and our surgical technique for its use is described.

Short gracilis myocutaneous flaps for vulvoperineal and inguinal reconstruction.

From October of 1990 to April of 1993, 16 short gracilis myocutaneous flaps and 1 short gracilis muscular flap were used to reconstruct vulvoperineal, inguinal, perineal, and ischial soft-tissue defects. Five of the 6 bilateral myocutaneous flaps were used for vulvoperineal reconstruction after radical vulvectomy combined with partial vaginectomy and one radical vulvectomy. Four unilateral myocutaneous flaps and one muscular flap were used for inguinal, suprapubic, ischial, and perineal reconstruction after release of contracted scar or excision of an ischial pressure sore. The immediate complications consisted of partial necrosis of the distal third of the cutaneous tissue in 6 patients, 1 superficial cutaneous necrosis, and superficial wound infection in 7 patients. The muscular portion of the flaps all survived. The follow-up period was from 6 to 27 months. The short gracilis flap has greater mobility than the classically described gracilis flap. On the basis of the functional and cosmetic results, the short gracilis flap is an excellent alternative to the more bulky classic gracilis flap.

Experience with the temporoparietal fascial free flap.

The temporoparietal fascia is an ideal tissue source for free transfer to distant sites where ultrathin coverage is either desirable or mandatory. The fascia's dependable vascular anatomy facilitates the technical aspects of microvascular transfer by means of its large vessels, ample pedicle, and ability to be grafted on either side. Furthermore, this highly vascular tissue is available in surprisingly large quantities, and its donor scar is hidden in the hair. The authors have found this flap useful (1) in covering exposed bone and tendon without adding unwanted bulk, (2) in providing thin flap coverage or lining in major facial reconstruction, (3) in covering vital structures such as exposed nerves and vessels, (4) in providing neovascularity both as a recipient graft bed and for control of chronic infection, and (5) in reestablishing gliding-tendon mechanisms. The authors have successfully employed this free flap in 15 cases which involved deformities of the ankle, foot, Achilles tendon, forearm, hand, nose, and contralateral ear and scalp. Seven cases are utilized to illustrate the broad application of this unique and versatile free flap.

Vascularized toe joint transfer to the hand.

From 1984 to 1993, 36 vascularized toe joints were transferred in 33 patients. The present study group excludes 3 toe joint transfers to elbow and temporomandibular joints and 4 toe joint to hand transfers lost to follow-up. The final study group includes 29 vascularized toe joint transfers in 27 patients, 21 males and 6 females. All were performed for posttraumatic reconstruction, except one transfer for congenital deformity. Follow-up averaged 32.4 months. Mean range of motion was 34 degrees in toe metatarsophalangeal joint to hand metacarpophalangeal joint transfers, 32 degrees in toe proximal interphalangeal joint to hand metacarpophalangeal joint transfers, and 24 degrees in toe proximal interphalangeal joint to hand proximal interphalangeal joint transfers. Although vascularized toe joint transfer is an alternative to arthrodesis, in order to have a greater range of motion than average, the patient must have well-functioning muscle and associated tendons effecting joint motion. Good results were obtained in two immediate free vascularized toe joint transfers to complex injuries involving loss of the metacarpophalangeal joint. We encourage toe joint transfer in selected complex hand injuries.