Effects of botulinum toxin A injection on healing and tensile strength of ruptured rabbit Achilles tendons.

BACKGROUND: Tendon lacerations are most commonly managed with surgical repair. Postoperative complications such as adhesions and ruptures often occur with immobilization. Early postoperative mobilization is therefore advised to minimize complications and time required to return to daily life. The aim of this study was to evaluate whether botulinum neurotoxin type-A (BoNT-A) can be used to enhance healing and prevent rupture in mobilized animals with Achilles tenotomy. METHODS: Twenty-seven rabbits were divided into 3 groups, namely, I, II, and III, after surgical 1-sided Achilles tenotomy and end-to-end repair. The control group for biomechanical comparisons consisted of randomly selected contralateral (unoperated) healthy Achilles tendons. Group I received BoNT-A (4 U/kg) injection into the calf muscles. One week later, electromyographical confirmation was performed to establish the effects of injection. Surgery was then performed. Animals in the second group (n = 9, group II) were immobilized with a cast postoperatively. The third group (n = 9, group III) was mobilized immediately with no cast or BoNT-A. Tendons were harvested and gap formation or ruptures as well as strength of the repaired tendon were assessed 6 weeks after surgery. RESULTS: Achilles tendons healed in all animals injected with BoNT-A, whereas all were ruptured in group III. All Achilles tendons of animals in groups I and II healed. However, group I repaired tendons were biomechanically equivalent to healthy tendons, whereas group II repaired tendons demonstrated significantly decreased tensile strength (P = 0.009). CONCLUSIONS: The present study suggests that local injection of BoNT-A can be used for treatment of tendon rupture and may replace the use of cast for immobilization. However, further studies are needed to determine whether BoNT-A injection can have a beneficial effect on the healing of tendon repairs in humans.

Reconstruction of a distal extremity defect using a temporoparietal fascia flap covered with a split-thickness skin graft harvested from the scalp: a cosmetic consideration in donor site selection.

BACKGROUND: In reconstructive surgery, the ultimate goal in rebuilding a structure is to provide the most similar substitute from both the functional and structural points of view. At the same time, the reconstructive surgeon should focus on minimizing donor area complications. METHODS: In this report, we present our experiences with the reconstruction of distal extremity defects using a free temporoparietal fascia flap in five patients. The flap was subsequently covered with a split-thickness skin graft harvested from the same region of the scalp as the flap donor site. RESULTS: By procuring the skin graft from the scalp, the donor sites of both the flap and the skin graft were concealed by hair. The transferred flaps and skin grafts healed uneventfully in all patients without any complications at the donor or recipient site. CONCLUSION: We conclude that this combination of harvesting a temporoparietal fascia flap, which has many advantages in reconstructing distal extremity defects, along with a skin graft from the same region as the flap, both hidden by hair, can limit donor site morbidity and achieve optimal reconstructive outcomes.

Median nerve excursion in response to wrist movement after endoscopic and open carpal tunnel release.

PURPOSE: To compare the perioperative kinematic effects of endoscopic versus open carpal tunnel release on longitudinal excursion (gliding) and volar displacement (bowstringing) of the median nerve at the wrist region in patients with idiopathic primary carpal tunnel syndrome. METHODS: Sixteen hands of 13 patients were randomly assigned into 2 groups (group 1, endoscopic; group 2, open carpal tunnel release). For the measurement of gliding and bowstringing of the median nerve, a metallic marker was used. Before and after the division of the transverse carpal ligament, longitudinal excursion and volar displacement of the median nerve were calculated based on fluoroscopic imaging for each wrist. Movement was analyzed for the measurement of the marker locations. RESULTS: The mean prerelease median nerve excursion during wrist range of motion was 20 mm (range, 10-28) in group 1 and 21 mm (range, 16-31 mm) in group 2. The mean postrelease median nerve excursion during wrist range of motion was 20 mm (range, 13-29) in group 1 and 18 mm (range, 8-26 mm) in group 2. There was no statistically significant difference in pre- and postrelease longitudinal excursion changes between the groups (p = .916 and p = .674, respectively). The mean prerelease volar displacement of the median nerve during wrist range of motion was 3 mm in group 1 and 4 mm in group 2; the postrelease mean values were 2 mm and 5 mm, respectively. There was no statistically significant difference between the groups with regard to pre- and postrelease volar displacement changes of the median nerve (p = .372 and p = .103, respectively). CONCLUSIONS: This study demonstrated that the endoscopic release and open carpal tunnel release produce similar perioperative effects on longitudinal and volar movements of the median nerve.

Median nerve excursion during endoscopic carpal tunnel release.

OBJECTIVE: Restriction of the excursion of the nerve has been accepted as a pathogenetic element in carpal tunnel syndrome. The goal of this article was to evaluate the median nerve excursion in the carpal tunnel measured as a function of wrist position before and after endoscopic carpal tunnel release (ECTR) on 28 hands of 22 patients. METHODS: The position of cylindrical stainless steel markers embedded within the median nerve was measured by a direct radiographic technique. Each upper extremity was examined in three wrist positions. Then, endoscopic release with Menon's technique was performed, and the measurements were repeated. RESULTS: In this prospective clinical study, most (93%) of the patients experienced resolution of their symptoms. Before and after ECTR, median nerve excursion was linear and was affected by wrist position. Before ECTR, when the wrist was moved from the end of dorsiflexion to the end of palmar flexion, the median nerve underwent a mean total excursion of 28.8 mm at the wrist. A comparison of the before and after ECTR excursion showed no statistical differences in the amount of motion. CONCLUSION: The single-portal ECTR does not seem to influence the median nerve excursion for the wrist positions studied in patients with carpal tunnel syndrome. The results from this in vivo study showed longitudinal gliding of the median nerve twice as great as in in vitro studies.

Endoscopic carpal tunnel release: modification of Menon's technique and data from 191 cases.

PURPOSE: Endoscopic carpal tunnel release using Menon's technique has been shown to reduce recovery time, although previous studies have shown that there is still a considerable risk of nerve complications. The purpose of this study was to evaluate data from 227 hands of 191 patients who underwent releases with Menon's technique. TYPE OF STUDY: Prospective study. METHODS: Endoscopic releases were performed as an outpatient intervention by one surgeon. Follow-up evaluations included were analysis of satisfaction, quantitative measurements of grip strength, return to work time, and complications. After the surgery on the first 50 hands in 41 consecutive cases, the technique was modified. Prospectively, changes in the technique are due to difficulties maintaining the knife within the center of the cannula's slot and a relatively high complication rate. In the modified technique, a 2.7-mm 25 degrees endoscope and a triangular diamond-tipped knife were used to allow for more room for the instruments and a more safe procedure. RESULTS: During the first month after the surgery, 91% of the patients had better subjective satisfaction scores and by 12 weeks, 81% obtained 75% to 100% or greater grip strength. Within 3 weeks, 70% of the patients had returned to work. Twelve of 50 hands operated on using the original technique had nerve disturbance diagnosed at follow-up. Three of these 12 patients developed reflex sympathetic dystrophy. One patient had partial median nerve injury that was repaired at the time of the index operation. There was no serious complication observed in 177 hands of 150 cases operated on using the modified Menon's technique, except one postoperative hypoesthesia along the long and ring fingers that improved with time. CONCLUSIONS: The procedure is suitable for outpatient surgery and the risk of inadvertent damage to the neurovascular structures can be dramatically reduced with the modifications to the technique. LEVEL OF EVIDENCE: Level IV.

Changes in tissue substance P levels in patients with carpal tunnel syndrome.

BACKGROUND: Although carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in adults, its etiology is not completely known. Chronic inflammation, fibrosis of the transverse carpal ligament (TCL), and altered sensory response contribute to the symptoms. OBJECTIVE: Because substance P (SP) is known to be involved in neuropathic pain, chronic inflammation, and fibrosis, the present study evaluated changes in SP levels in patients with CTS. METHODS: TCL, median nerve adventitia, and synovial connective tissue of the middle flexor digitorum superficialis tendon samples from patients (n=42) with CTS and healthy control subjects (n=13) who were operated on for hand wounds were obtained at surgery. A group of these patients with CTS (n=9) had received meloxicam treatment for 10 days before surgery. A 2-step acetic acid extraction was used to determine changes in SP levels in free nerve endings (neuronal) and in nonneuronal cells. RESULTS: Changes in SP levels were observed in both neuronal and nonneuronal tissues. SP levels increased in extracts of the TCL and synovial connective tissue of the middle flexor digitorum superficialis tendon but not in the median nerve adventitia of patients with CTS. Meloxicam pretreatment increased SP levels in nonneuronal components of the TCL. CONCLUSION: These findings suggest that SP contributes to the pain and inflammation associated with CTS. Further studies are required to evaluate the therapeutic potentials of SP receptor (NK1R) antagonists in CTS.

Effects of intrathecal administration of FK506 after sciatic nerve crush injury.

Although various administration routes of FK506 have been published, intrathecal administration of FK506 has not previously been reported in the literature. A daily dose of 0.05 mg/kg of FK506 was given (a small dose compared with those reported in the available literature). The authors used this small dose to obtain lower immunosuppression and neurotoxicity, and a higher axonal regeneration rate. A total number of 40 female Wistar rats were used and randomly divided into four groups: control, sham, FK506-treated, and vehicle-treated. Sciatic nerve regeneration was evaluated by walking track analysis, an electrostimulation test, and light microscopic evaluation. There was a statistically significant difference ( P < 0.05) between FK506-treated and vehicle-treated groups at the end of 6 weeks according to both the walking track analysis and the electrostimulation test. Comparing the stimulus thresholds of the sham and FK506-treated group, no significant difference ( P > 0.05) was observed. Evaluation of the data revealed that FK506 had a beneficial effect on sciatic nerve regeneration.

Juxta-articular myxoma of the wrist: a case report.

A 16-year-old boy with a 4-month history of pain and a palpable mass in the right wrist was presented to our clinic. Preoperative diagnosis was a ganglion cyst according to symptoms and physical examination. The lesion was removed by marginal resection and histopathologic examination revealed a juxta-articular myxoma. No recurrence was detected at 1-year follow-up evaluation. We report a case of juxta-articular myxoma of the wrist joint.

Results of zone II flexor tendon repair in children younger than age 6 years: botulinum toxin type A administration eased cooperation during the rehabilitation and improved outcome.

The inability of young children with a zone II flexor tendon repair to cooperate in postoperative care and rehabilitation may represent a high risk for medical and surgical complications. To forestall that risk, botulinum toxin type A (2.5 U/kg, 7 U/kg) injection was used during surgery to induce forearm flexor muscle relaxation in seven children under 6 years old with zone 2 flexor tendon repairs. Patients received a controlled passive motion regimen after surgery. Results were evaluated on the basis of the acquisition of muscle tone and active finger movements, total range of motion of affected joints, postoperative grip strength, muscle atrophy, and phalangeal length. In this prospective clinical study, the mean follow-up was 18 months. All the children had good and excellent results based on the Strickland criteria. As for postoperative complications, one patient had bowstring and another had poor finger sensibility and first web space contracture that required Z-plasty. The selective use of botulinum toxin type A to weaken the targeted muscles generated a sufficient reduction in spontaneous activity of the fingers, permitting an improved rehabilitation program. Botulinum toxin type A administration could be an effective form of therapy, serving as an alternative or adjunct to conventional rehabilitation modalities in these children.