Surgical outcomes following nerve transfers in upper brachial plexus injuries.

BACKGROUND: Brachial plexus injuries represent devastating injuries with a poor prognosis. Neurolysis, nerve repair, nerve grafts, nerve transfer, functioning free-muscle transfer and pedicle muscle transfer are the main surgical procedures for treating these injuries. Among these, nerve transfer or neurotization is mainly indicated in root avulsion injury. MATERIALS AND METHODS: We analysed the results of various neurotization techniques in 20 patients (age group 20-41 years, mean 25.7 years) in terms of denervation time, recovery time and functional results. The inclusion criteria for the study included irreparable injuries to the upper roots of brachial plexus (C5, C6 and C7 roots in various combinations), surgery within 10 months of injury and a minimum follow-up period of 18 months. The average denervation period was 4.2 months. Shoulder functions were restored by transfer of spinal accessory nerve to suprascapular nerve (19 patients), and phrenic nerve to suprascapular nerve (1 patient). In 11 patients, axillary nerve was also neurotized using different donors - radial nerve branch to the long head triceps (7 patients), intercostal nerves (2 patients), and phrenic nerve with nerve graft (2 patients). Elbow flexion was restored by transfer of ulnar nerve motor fascicle to the motor branch of biceps (4 patients), both ulnar and median nerve motor fascicles to the biceps and brachialis motor nerves (10 patients), spinal accessory nerve to musculocutaneous nerve with an intervening sural nerve graft (1 patient), intercostal nerves (3rd, 4th and 5th) to musculocutaneous nerve (4 patients) and phrenic nerve to musculocutaneous nerve with an intervening graft (1 patient). RESULTS: Motor and sensory recovery was assessed according to Medical Research Council (MRC) Scoring system. In shoulder abduction, five patients scored M4 and three patients M3+. Fair results were obtained in remaining 12 patients. The achieved abduction averaged 95 degrees (range, 50 - 170 degrees). Eight patients scored M4 power in elbow flexion and assessed as excellent results. Good results (M3+) were obtained in seven patients. Five patients had fair results (M2+ to M3).

Management strategy for facial arteriovenous malformations.

Arteriovenous malformations (AVMs) are uncommon errors of vascular morphogenesis; haemodynamically, they are high-flow lesions. Approximately 50% of AVMs are located in the craniofacial region. Subtotal excision or proximal ligation of the feeding vessel frequently results in rapid progression of the AVMs. Hence, the correct treatment consists of highly selective embolisation (super-selective) followed by complete resection 24-48 hours later. We treated 20 patients with facial arteriovenous malformation by using this method. Most of the lesions (80%) were located within the cheek and lip. There were no procedure related complications and cosmetic results were excellent.

Microbiological safety and clinical efficacy of radiation sterilized amniotic membranes for treatment of second-degree burns.

Amniotic membranes collected from the placentae of screened donors were processed and sterilized by gamma irradiation at 25 kGy. The sterility assurance level (SAL) of gamma irradiated amniotic membranes and clinical efficacy in second-degree burn wound healing were evaluated. Processed air-dried amniotic tissue from 159 batches of processing was checked for the bioburden level before sterilization. About 39% of the tissues had bioburden in the range of 10(1)-10(2)/100 cm(2) and 54.8% in the range of 10(2)-10(3)/100 cm(2). Based on the bioburden of the processed tissue prior to sterilization and the D(10) value of 2.3 kGy for the radiation resistant reference strain Bacillus pumilus, the sterility assurance level of the amniotic membranes irradiated at 25 kGy is found to be 10(-7) to 10(-11). The burn wound healing rate was compared between the radiation sterilized amniotic membranes and glycerol preserved amniotic membranes. Fifty patients with partial-thickness burns (up to 70% TBSA) were selected for the study. The scalds constituted 82% (41 patients) whereas flame burns accounted for 18% (9 patients). Various aspects like ease of application, patient comfort, development of fluid under the membrane, bacterial culture of drained fluid, rate of epithelialization, development of hypertrophic scars, keloids, unstable scars and restriction of joint movements were recorded with the application of gamma irradiated and glycerol preserved membranes. Radiation sterilized amniotic membranes had advantage over the glycerolized membranes with respect to the ease of application. Five patients with glycerol preserved membranes and four with gamma irradiated membranes developed fluid. The bacteriology of fluid showed Pseudomonas aeruginosa in four cases, Staphylococcus aureus in two cases, Escherichia coli in two cases and Acinetobacter in one case. The application of radiation sterilized amniotic membranes on the burn wound favoured epithelialization. In all the patients, membranes dessicated and separated in 10-14 days time leaving behind an epithelialized surface.

Reconstruction of Complex Abdominal Wall Defects.

INTRODUCTION: Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. These defects result from trauma, previous surgery, infection and tumour resection. The primary objectives of abdominal wall reconstructions are to protect abdominal contents and provide functional support. The abdominal wall reconstruction aims at providing basic component parts, i.e. skin, soft tissue and fascia. For large soft tissue defects, pedicled or free flap closure can be used. In clean wounds, fascial replacement is accomplished with synthetic mesh provided there is adequate soft tissue coverage. METHODS: We treated a total of 20 consecutive patients with complex abdominal wall defects utilizing various reconstructive procedures. There were 15 males (75%) and 5 females (25%). The aetiology included dehiscence of laparotomy wounds in eight (40%), following ablative surgery for malignant tumours in seven (35%), trauma in three (15%) and congenital defects in two (10%) cases. The reconstructive procedures consisted of onlay prolene mesh in seven (35%), Gore-Tex (PTFE) dual mesh both as inlay and onlay in five (25%), facial partition release technique in three (15%), inlay prolene mesh covered with omentum and split skin graft in two (10%), inlay prolene mesh covered with expanded skin in two (10%), and Gore-Tex dual mesh covered with latissimus dorsi myocutaneous flap in one (5%) case. Postoperatively none developed mesh infection or extrusion. Three patients with malignant aetiology received postoperative radiotherapy. During follow up, one patient developed ventral hernia cephalad to the repair and one died due to recurrence of abdominal wall malignancy. CONCLUSION: The reconstruction of an abdominal wall defect requires a comprehensive plan of preoperative and post operative care of the patient and aims toward restoration of abdominal structural integrity by a variety of procedures. The use of new biomaterials and tissue expanders provides reliable and durable abdominal wall closure along with good aesthetic results.

Management of Soft Tissue Defects of the Ankle and Foot.

BACKGROUND: Treatment of soft tissue defect of ankle and foot has always been a challenging problem. METHODS: Thirty patients with soft tissue defects of the ankle and foot who underwent various reconstructive procedures in two tertiary care teaching hospitals were studied. RESULTS: Most of the defects (33%) were located in and around the ankle. Trauma was the major cause (56.6%). Defects were reconstructed with a variety of local, regional, distant and microvascular free flaps. Distally based superficial sural artery flap was used in majority of the cases (40%). Free tissue transfer using radial artery forearm flap was done in three (10%) complex wounds where other flaps were not found to be suitable. Superficial soft tissue defects on the dorsum of foot were resurfaced with split thickness skin grafts in 3 (10%) cases. Out of 27 flaps used, 26 survived completely. One inferiorly based fasciocutaneous flap developed partial necrosis. There was graft loss in one patient which required regrafting with the stored autograft. CONCLUSION: Distally based superficial sural artery flap remains the choice for reconstruction of soft tissue defects of ankle and foot because of its reliable blood supply and easy elevation.

Distraction - A Minimally Invasive Technique for Treating Camptodactyly and Clinodactyly.

Camptodactyly and clinodactyly are relatively common congenital anomalies affecting about 1% to 2% of the general population. Though functional impairment is uncommon other than in very severe cases, patients affected do present very often for correction. The kind of surgeries available is as diverse as the aetiology of the conditions. It ranges from simple release of the flexor digitorum sublimis (FDS) to more complex small muscle transfers, rebalance etc. In this short series a relatively easier, minimally invasive technique of distraction has been used to correct these deformities with gratifying results.

"Amnion Bank"--the use of long term glycerol preserved amniotic membranes in the management of superficial and superficial partial thickness burns.

With about 2 million cases of burns in India of which about 90% are superficial and superficial partial thickness burns, burn injuries present a major challenge to the scarce medical resources available. The main requirement in treating these burns is an economical, easy to apply, readily available dressing that will provide good pain relief, protect the wound from infection, promote healing, prevent heat and fluid loss, be elastic and non-antigenic and adhere well to the wound. It was in the quest of such an ideal dressing that the Burn Centre of the Army Hospital (Research and Referral) New Delhi, India has been using human amniotic membranes preserved long term in 85% glycerol for treating these wounds. The results of this quest have resulted in a protocol where these long term glycerol preserved membranes (some of which have now been preserved for about 2.5 years) are used for treating superficial and superficial thickness burns presenting at our center. This paper shows the excellent results obtained with the use of this extremely economical dressing and emphasizes the importance of establishing such "Amnion Banks" in all hospitals especially in developing countries.

MICROSURGICAL COMPOSITE TISSUE TRANSPLANTATION: A CLINICAL TRIAL.

Twenty four patients suffering from various ailments necessitating flap cover were treated with composite tissue transplantation by microsurgical techniques from July 1992 to July 1996. There were 21 males and 3 females in the 10 to 50 years age group. Four patients were provided flap cover on the face for congenital lesions and twenty patients required flap cover for sub acute/chronic trauma. The radial artery forearm and latissimus dorsi were the most commonly used flaps in this study. Seventeen patients had excellent and four patients had acceptable cosmetic and functional results. Three flaps were lost due to vascular problems.