Upper limb functional restoration in old and complete brachial plexus paralysis.

Nineteen patients with longstanding and permanent brachial plexus injuries underwent a three-staged surgical reconstruction. First, a sural nerve was grafted from the contralateral intact medial pectoral nerve to the paralyzed arm. One year later, a free gracilis muscle was transferred and neurotized by the grafted sural nerve. This procedure results in reanimation of elbow flexion. Finally, the biceps tendon was transferred to the finger flexors using a fascia bundle of tensor fascia lata muscle. Two of the gracilis muscle free transfers failed. In the remaining 17 patients, the overall result was evaluated as satisfactory in 11 patients and good in 6.

Super-thin abdominal skin pedicle flap for the reconstruction of hypertrophic and contracted dorsal hand burn scars.

Dorsal contracture is one of the most common complications of burned hand and can result in a spectrum of deformities and functional disabilities. The injury usually necessitates surgical reconstruction and to the majority of patients, cosmetic end result is a very important issue. In this retrospective study, the authors present the technique of super-thin skin abdominal pedicle flap for the treatment of dorsal hand hypertrophic burn contracture, and review the results. Overall 42 medium or large hypertrophic and contracted scars of the dorsal hand in 34 patients were treated using this procedure. Generally, the functional and aesthetic outcomes were evaluated as good. The functional results were comparable to employment of other types of flap with no relapse of contracture. From the aesthetic point of view, the reconstructed skin was similar to the skin of the rest of the extremity, with good color match, bulkiness, laxity, and suppleness. The scar of the donor region was comparable to the scar of abdominoplasty procedures on the ipsi-lateral side of the lower abdomen. Therefore, this procedure can be considered a reliable and technically simple modality in the treatment of dorsal hand burn contractures.

Surgical technique for the treatment of C5 and C6 root avulsion.

C5 and C6 root avulsion is generally treated by neurotization of musculocutaneous (M.C.) nerve by spinal accessory (S.A.) or intercostal nerve, and neurotization of supra-scapular nerve by spinal accessory. For the last few years, permanent paralysis of C5 and C6 root has been treated by neurotization of musculocutaneous nerve by one or two fascicles of the ulnar or median nerve, and axillary nerve by a few fascicles of the radial nerve. Eighteen patients with M.C. nerve paralysis were treated by end-to-end suture of one or two fascicles of the ulnar nerve. Patients were followed for 4 years. Neurotization of M.C. nerve by a few fascicles of ulnar or median nerve, and axillary nerve by two fascicles of radial nerve were performed by end-to-end suture. The operative technique is easy and results are good. However, with previous procedures, neurotization of the mentioned nerves usually requires a 6-8 cm nerve graft. With this length of graft, the recovery period is longer than with end-to-end suture. Furthermore, if more than 9 months have passed since the onset of paralysis, especially for axillary nerve, usually good functional results are not obtained. Also, both axillary and radial nerves are the branches of posterior cord, and hence CNS adaptation is more easily attained. Therefore, we recommend the use of this new technique for the treatment of C5 and C6 root avulsion, since the operative time is shorter and procedure is easier for the surgeon. Also recovery period is shorter.

Transfer of a single flexor carpi ulnaris tendon for treatment of radial nerve palsy.

Between 1993 and 2002, 108 patients with isolated and persisting radial nerve palsy, underwent transfer of the flexor carpi ulnaris tendon alone to extensor digitorum communis, extensor indicis proprius and extensor pollicis longus. Only patients with sufficient flexor carpi ulnaris muscle power (grade M5) underwent this procedure. Long-term functional results were reviewed at a mean postoperative follow up of 48 (range 3-120) months. In comparison with the contralateral hand, the range of extension of the wrist was less but extension of the fingers and the MCP joints were similar to that of the normal hand. All patients improved functionally and could cope with their routine activities. Most were able to return to their previous jobs. There was no obvious difference in the end result of using this single transfer from our previous results using the three tendon transfers which are commonly used to treat radial nerve palsy. The single flexor carpi ulnaris tendon transfer has some advantages in terms of simplicity, shorter operation time, less morbidity and less surgical scars.

The extended latissimus dorsi muscle island flap for flexion or extension of the fingers.

We describe the technique of transferring the latissmus dorsi muscle as an island flap for the restoration of digital flexion or extension in 28 patients. The latissmus dorsi muscle is raised down to the posterior iliac crest and prolonged with the gluteal superficial facia. We believe that this method is particularly suitable for extensive and prolonged paralysis of the lower elements of brachial plexus. It can be used also for severe Volkmann's contracture or the loss of flexor or extensor muscles of the fingers due to extensive debridement. The technique does not require microsurgery and there is no delay in reinnervation of the muscle.

[Analytical study of the treatment of facial paralysis by hypoglossal-facial anastomosis. Apropos of 25 cases]. / Etude analytique du traitement de la paralysie faciale par anastomose hypoglosso-faciale. A propos de 25 cas.

Hypoglosso-facial anastomosis (HFA) is an already old alternative for the surgical treatment of facial paralysis. 25 patients, 17 men and 8 women, with complete facial paralysis were operated according to this technique, 6 to 12 months after onset of the paralysis. Based on analysis of the results, the authors describe the advantages and disadvantages of this technique. The advantages are: facial symmetry at rest, protection of the cornea, voluntary movements of facial muscles. The disadvantages are: paralysis and atrophy of one side of the tongue, absence of expression of emotional and involuntary states on one half of the face, synkinesia, disorders of mastication. Disorders of deglutition improve with time. In this series of 25 patients, the authors never observed eyelid movements independent of movements of the labial commissure. By comparing these advantages and disadvantages, the authors consider that HFA should no longer be proposed for the treatment of facial paralysis. In the current state of microsurgery, if the facial nerve cannot be repaired by direct suture or graft, the authors recommend revascularized, reinnervated muscle transfer onto the facial nerve of the healthy side.

[Reconstruction of chronic facial paralysis by free gracilis muscle transfer. Apropos of 59 cases]. / Reconstruction des paralysies faciales anciennes par transfert musculaire libre de Gracilis. A propos de 59 cas.

Surgical repair of facial paralysis is designed to restore automatic and uniform facial expression. The authors report their experience of 64 patients with longstanding facial paralysis treated by revascularized and reinnervated gracilis muscle transfer. Reinnervation of the gracilis muscle was obtained by anastomosis of its motor nerve to the facial nerve on the healthy side following preliminary transfacial nerve graft. 59 patients were followed for 1 to 8 years; the mean duration of facial paralysis was 14 years in this series. The authors modified the gracilis muscle harvesting technique by decreasing the muscle mass to a minimum. Two complications were observed: one severe infection leading to thrombosis of the anastomosed vessels and one intraoperative technical difficulty concerning the nerve anastomosis. The results were considered to be good in 72% of cases and excellent in 5% of cases in terms of facial expression. However, good results were not obtained in muscle transfer for palpebral paralysis, in which the authors prefer to make the eyelid heavier by inserting a gold weight implant after modifying this technique to lower the rejection rate.

[Value of a free osteocutaneous flap from the second metatarsal bone in the management of substance loss in the forearm, caused by gunshot wounds. Apropos of an experience in 28 cases]. / Intérêt du lambeau libre ostéocutané du deuxième métatarsien dans le traitement des pertes de substance de l'avant-bras secondaries à un traumatisme balistique. A propos d'une expérience de 28 cas.

The authors report their experience of the secondary treatment of forearm defects secondary to gunshot injuries. The lesions encountered involved both soft tissues and bone. After using classical techniques consisting of fibula or iliac crest osteocutaneous free flaps, they used, whenever possible, a second metatarsal osteocutaneous free flap, which enabled them to conduct a comparative study of these different procedures and they concluded on the superiority of this latter type of flap. Their experience is based on 28 cases, including 16 cases of second metatarsal osteocutaneous free flap.

[War injuries of the femoral nerve. Apropos of a series of 27 cases]. / Les blessures de guerre du nerf crural. A propos d'une série de vingt-sept cas.

The authors report a series of 27 war injuries to the femoral nerve which represent approximately 1% of all of the war injuries to peripheral nerves operated in our department since the Islamic revolution in Iran in 1978 and during the 8 years of the war between Iran and Iraq. All of the victims presented with associated lesions: abdominal (24 laparotomies, including 10 colostomies) and/or vascular (3 iliac artery by-pass grafts). We divided the cases into 3 groups. In Group 1 (18 cases), the femoral nerve had a mean defect of 8 centimetres which was grafted. In Group 2 (4 cases), the nerve was simply compressed by fibrosis and/or metallic bodies and was released. In Group 3 (5 cases), the nerve trunk had a partial loss of substance which was grafted. The motor results were very satisfactory (M3 to M5) in the 3 groups with muscular recovery in about 2 years.