Improving Outcomes in Immediate and Delayed Nerve Grafting of Peripheral Nerve Gaps Using Light-Activated Sealing of Neurorrhaphy Sites with Human Amnion Wraps.

BACKGROUND: Photochemical tissue bonding uses visible light to create sutureless, watertight bonds between two apposed tissue surfaces stained with photoactive dye. When applied to nerve grafting, photochemical tissue bonding can result in superior outcomes compared with suture fixation. Our previous success has focused on immediate repair. It was the aim of this study to assess the efficacy of photochemical tissue bonding when performed following a clinically relevant delay. METHODS: Forty male Lewis rats had 15-mm left sciatic nerve gaps repaired with reversed isografts immediately (n = 20) or after a 30-day delay (n = 20). Repairs were secured using either suture or photochemical tissue bonding. Rats were killed after 150 days. Outcomes were assessed using monthly Sciatic Function Index evaluation, muscle mass retention, and nerve histomorphometry. Statistical analysis was performed using analysis of variance and the post hoc Bonferroni test. RESULTS: In both immediate and delayed groups, photochemical tissue bonding showed a trend toward greater recovery of Sciatic Function Index, but these results were not significant. The Sciatic Function Index was significantly greater when performed immediately. Significantly greater muscle mass retention occurred following photochemical tissue bonding in both immediate and delayed repairs. Values did not differ significantly between immediate and delayed groups. Histomorphometric recovery was greatest in the immediate photochemical tissue bonding group and poorest in the delayed suture group. Fiber diameter, axon diameter, myelin thickness, and G-ratio were not significantly different between immediate suture and delayed photochemical tissue bonding. CONCLUSIONS: Light-activated sealing of nerve grafts results in significantly better outcomes in comparison with conventional suture. The technique not only remains efficacious but may also help ameliorate the detrimental impacts of surgical delay.

Light-Activated Sealing of Acellular Nerve Allografts following Nerve Gap Injury.

Introduction Photochemical tissue bonding (PTB) uses visible light to create sutureless, watertight bonds between two apposed tissue surfaces stained with photoactive dye. In phase 1 of this two-phase study, nerve gaps repaired with bonded isografts were superior to sutured isografts. When autograft demand exceeds supply, acellular nerve allograft (ANA) is an alternative although outcomes are typically inferior. This study assesses the efficacy of PTB when used with ANA. Methods Overall 20 male Lewis rats had 15-mm left sciatic nerve gaps repaired using ANA. ANAs were secured using epineurial suture (group 1) or PTB (group 2). Outcomes were assessed using sciatic function index (SFI), gastrocnemius muscle mass retention, and nerve histomorphometry. Historical controls from phase 1 were used to compare the performance of ANA with isograft. Statistical analysis was performed using analysis of variance and Bonferroni all-pairs comparison. Results All ANAs had signs of successful regeneration. Mean values for SFI, muscle mass retention, nerve fiber diameter, axon diameter, and myelin thickness were not significantly different between ANA + suture and ANA + PTB. On comparative analysis, ANA + suture performed significantly worse than isograft + suture from phase 1. However, ANA + PTB was statistically comparable to isograft + suture, the current standard of care. Conclusion Previously reported advantages of PTB versus suture appear to be reduced when applied to ANA. The lack of Schwann cells and neurotrophic factors may be responsible. PTB may improve ANA performance to an extent, where they are equivalent to autograft. This may have important clinical implications when injuries preclude the use of autograft.

Light-Activated Sealing of Nerve Graft Coaptation Sites Improves Outcome following Large Gap Peripheral Nerve Injury.

BACKGROUND: Nerve repair using photochemically bonded human amnion nerve wraps can result in superior outcomes in comparison with standard suture. When applied to nerve grafts, efficacy has been limited by proteolytic degradation of bonded amnion during extended periods of recovery. Chemical cross-linking of amnion before bonding may improve wrap durability and efficacy. METHODS: Three nerve wraps (amnion, cross-linked amnion, and cross-linked swine intestinal submucosa) and three fixation methods (suture, fibrin glue, and photochemical bonding) were investigated. One hundred ten Lewis rats had 15-mm left sciatic nerve gaps repaired with isografts. Nine groups (n = 10) had isografts secured by one of the aforementioned wrap/fixation combinations. Positive and negative control groups (n = 10) were repaired with graft and suture and no repair, respectively. Outcomes were assessed using sciatic function index, muscle mass retention, and histomorphometry. Statistical analysis was performed using analysis of variance and the post hoc Bonferroni test (p < 0.05). RESULTS: Cross-linking improved amnion durability. Photochemically bonded cross-linked amnion recovered the greatest sciatic function index, although this was not significant in comparison with graft and suture. Photochemically bonded cross-linked amnion recovered significantly greater muscle mass (67.3 ± 4.4 percent versus 60.0 ± 5.2 percent; p = 0.02), fiber diameter, axon diameter, and myelin thickness (6.87 ± 2.23 µm versus 5.47 ± 1.70 µm; 4.51 ± 1.83 µm versus 3.50 ± 1.44 µm; and 2.35 ± 0.64 µm versus 1.96 ± 0.47 µm, respectively) in comparison with graft and suture. CONCLUSION: Light-activated sealing of cross-linked human amnion results in superior outcomes when compared with conventional suture.

Augmenting peripheral nerve regeneration using stem cells: A review of current opinion.

Outcomes following peripheral nerve injury remain frustratingly poor. The reasons for this are multifactorial, although maintaining a growth permissive environment in the distal nerve stump following repair is arguably the most important. The optimal environment for axonal regeneration relies on the synthesis and release of many biochemical mediators that are temporally and spatially regulated with a high level of incompletely understood complexity. The Schwann cell (SC) has emerged as a key player in this process. Prolonged periods of distal nerve stump denervation, characteristic of large gaps and proximal injuries, have been associated with a reduction in SC number and ability to support regenerating axons. Cell based therapy offers a potential therapy for the improvement of outcomes following peripheral nerve reconstruction. Stem cells have the potential to increase the number of SCs and prolong their ability to support regeneration. They may also have the ability to rescue and replenish populations of chromatolytic and apoptotic neurons following axotomy. Finally, they can be used in non-physiologic ways to preserve injured tissues such as denervated muscle while neuronal ingrowth has not yet occurred. Aside from stem cell type, careful consideration must be given to differentiation status, how stem cells are supported following transplantation and how they will be delivered to the site of injury. It is the aim of this article to review current opinions on the strategies of stem cell based therapy for the augmentation of peripheral nerve regeneration.

The role of hybrid SPECT/CT for lymphatic mapping in patients with melanoma.

INTRODUCTION: Lymphoscintigraphy in melanoma provides important information on the dynamic drainage of the primary tumour and the location of the sentinel lymph node (SLN). Unfortunately these images lack anatomical detail. Single positron emission computed tomography/computed tomography (SPECT/CT) provides extremely detailed information on the location of the SLN and its relationship with surrounding structures and it is the aim of this study to report our initial experience with this technology. METHODS: Thirty-two patients undergoing sentinel lymph node biopsy (SLNB) at our unit between October 2010 and October 2011 were included in this study. In each case, conventional planar lymphoscintigraphy (PL) was followed by SPECT/CT. Images of each patient were reviewed by the operating consultant plastic surgeon and a consultant radiologist. A joint opinion was issued on the number of lymph nodes identified by each imaging modality and whether SPECT/CT influenced surgical approach. RESULTS: Both PL and SPECT/CT detected the SLN in 31/32 patients. There was no significant difference between the number of SLN identified by PL and SPECT (p = 0.69). In relation to the true number of SLNs identified intra-operatively by gamma probing and blue dye, there was no statistically significant difference in accuracy between SPECT/CT and PL (p = 0.50). SPECT/CT was judged to provide useful anatomical information in all cases. Surgical approach was altered in 12/32 patients and contributed to the detection of SLNs that were positive for metastases. CONCLUSIONS: In relation to true SLN number, SPECT/CT was not significantly more accurate than PL. The detailed anatomical information provided by SPECT/CT improved confidence and pre-operative planning in all patients. In select cases, particularly in the head and neck, SPECT/CT overcame the limitations of PL and facilitated the detection and sampling of metastatic nodes.

Sentinel lymph node biopsy in thick malignant melanoma: a 10-year single unit experience.

Between the years 2000-2010, 195 patients were diagnosed with ≥4 mm Breslow thickness malignant melanoma in our unit. Median follow-up was 36.8 months. 49% of patients were male and 51% were female. Median age was 74 years. The commonest melanoma type was nodular (55%). The commonest tumour location was on the extremity (45%). 64% of tumours were ulcerated. Median mitotic rate was 9. Median Breslow thickness was 7 mm 66 patients underwent sentinel lymph node biopsy. 44 (67%) patients had negative results and the remaining 22 (33%) patients were positive for metastatic melanoma. There was no statistically significant correlation between any of the patient or tumour variables (age, sex, melanoma type, melanoma site, Clark level, Breslow thickness, mitotic rate, ulceration) and sentinel lymph node status. Patients with Breslow thickness melanoma of <6 mm had a significantly better 5-year disease free and overall survival compared with those patients with >6 mm Breslow thickness melanoma (63.5% vs. 32.9%; P=0.004 and 73.9% vs. 54.7%; P=0.02 respectively). Recurrence rate was 50% in those with positive sentinel lymph node biopsy compared to 23% in those with negative results. Distant recurrence was the commonest in both groups. 5-year disease free survival was 64.1% in the SLNB -ve group and 35.4% in the SLNB +ve group (P=0.01). There was no significant difference in overall survival between the SLNB -ve and SLNB +ve groups (70.3% vs. 63.7% respectively; P=0.66). We conclude that sentinel lymph node biopsy in our unit has provided no survival benefit in those with thick melanoma over the past 10 years but is an important predictor of recurrence free survival. Breslow thickness remains an important predictor of disease free and overall survival in thick melanoma.

No such thing as "just" a nail bed injury.

Nail bed injuries are the commonest pediatric hand injuries presenting to the emergency department. If managed correctly, the patient recovers quickly and complications are rare. However, failure to appreciate the complex anatomy of the perionychium and the importance of exploration, washout, and repair can result in devastating complications. These injuries are often underestimated and, consequently, delegated to the most junior and inexperienced staff. The case of a 6-year-old boy with a flexor sheath infection and devitalized fingertip 1 week after injury is presented. Emphasis is placed on the soft tissue and underlying bony injury that was overlooked at initial presentation, and how this led to serious infection requiring amputation. Thorough assessment of these common injuries and a high index of suspicion are essential.

Findings of computed tomography in stage IIB and IIC melanoma: a six-year retrospective study in the South-East of Scotland.

INTRODUCTION: Patient prognosis in malignant melanoma is directly related to clinical stage, and accurate staging is key to appropriate management. Revised BAD/BAPS (British Association of Dermatologists/British association of Plastic Surgeons) 2010 guidelines for the management of cutaneous melanoma recommend that Computed Tomography (CT) is no longer indicated for AJCC (American Joint Cancer Committee) IIB and IIC disease (Breslow thickness 2.01 - 4 mm with ulceration or >4 mm), unless the patient is symptomatic. Previous UK guidelines had recommended that all patients with AJCC IIB or worse disease should have chest, abdomen and pelvic CT as staging investigations. New guidelines also now include head CT in their recommendations. Our aim was to investigate regional CT findings in those patients diagnosed with AJCC IIB and IIC disease, and establish whether our findings affirmed new UK guidelines. METHODS AND PATIENT GROUP: A retrospective review of case notes was performed on 172 cases of AJCC IIB and IIC disease referred across Lothian, Borders and Fife to melanoma services during the period of January 2004 to January 2010. Clinical findings, results of initial and follow-up CT scans along with changes in patient management were noted. Chest, abdomen and pelvic CT scan were defined as one scan as they were always performed together. CT head and CT neck were defined as separate scans. A positive CT result was defined as those reported with metastasis or an indeterminate result leading to further investigations. Change in management was defined as specific active treatment started or stopped eg surgery or chemo/radiotherapy. RESULTS: A total of 269 scans were performed on 130/172 patients. One hundred and four initial staging CT scans were performed on 75 patients, and detected one (1.3%) occult melanoma metastasis. At follow-up, 165 scans were performed in 82 patients and detected 56 metastasis in 32(39%) patients leading to a change in management in 29(35%). Two of these 32 patients had occult melanoma metastasis. Symptomatic patients had statistically significant more metastatic disease diagnosed at follow-up CT scanning than asymptomatic patients p < 0.0001. Head CT detected 15/56 (27%) of all metastasis. CONCLUSION: CT scanning should only be performed in AJCC IIB and IIC melanoma patients if symptoms of clinical metastatic disease are present. Head CT should be included in the staging process. Our regional results concur with new BAD/BAPS 2010 guidelines.

Management of Marjolin's ulcer in a chronic pressure sore secondary to paraplegia: a radical surgical solution.

Marjolin's ulcer refers to malignant degeneration in a chronic wound. Although originally described in an area of burns scar, many other chronic wounds such as osteomyelitis sinus tracts, venous stasis ulcers and chronic pressure sores have the potential to undergo malignant transformation. We present an interesting case of malignant degeneration in a male paraplegic patient with chronic sacral and ischial pressure sores. By discussing our radical surgical solution to this problem, we aim to highlight the importance of prompt diagnosis.