Compound flap from the great toe and vascularized joints from the second toe for posttraumatic thumb reconstruction at the level of the proximal metacarpal bone.

The purpose of this study is to describe the harvesting technique, anatomic variations, and clinical applications of a compound flap from the great toe and vascularized joint from the second toe used for thumb reconstruction. Five fresh cadaver dissections were studied, focusing attention on the dorsal or plantar vascular dominance, position of the communicating branch between the dorsal and plantar system, the Gilbert classification, and the size of the first dorsal metatarsal artery (FDMA) and first plantar metatarsal artery (FPMA) to the great toe and second toe. Five compound flaps were performed on five patients with traumatic thumb amputation at the level of proximal metacarpal bone. The patients' ages ranged from 14 to 47. Follow-up period was 11-24 months. The anatomic study showed that FPMA had larger caliber in 40% of dissections, FDMA in 40%, and had the same caliber in 20%. The Gilbert classification of FDMA was 40% class I and 60% class III. In the clinical applications, four patients achieved good functional opposition and motion of transferred joints with good pinch and grip strength. There was one flap failure, and donor-site morbidity was minimal. The compound flap offers advantages over traditional toe transfer by providing two functional joints. It can be used for amputation of the thumb at carpometacarpal joint level. Finally, the compound flap maintains growth potential in children through transfer of vascularized epiphyses. The disadvantages of this compound flap include a technically challenging harvest and a longer operative time.

[Impact of loss of sympathetic innervation on peripheral nerve regeneration: an experimental study with rats].

OBJECTIVE: To investigate the impact of loss of sympathetic innervation on peripheral nerve regeneration. METHODS: Thirty-two SD rats underwent resection of the right middle cervical ganglion and excision and re-anastomosis of bilateral medium nerve, and then were randomly divided into 4 equal groups to undergo the following experiments. One, 2, 3, and 4 weeks later the sensory nerve action potentials (SNAPs) of bilateral medium nerves 5 mm from the anastomotic stoma and the compound muscle action potentials (CMAPs) of bilateral superficial digital flexor muscles were measured with stimulating and recording electrodes. Specimens of the distal part of bilateral medium nerves 5 mm from the anastomotic stoma were collected to calculate the number of modulated fibers by electron microscopy. The tendons of bilateral superior digital flexor muscles were cut ant the wrist, isolated to the terminal points, ligated, and connected to a sensor so as to record the maximum contraction power. The superior digital flexor muscle was completely resected to be weighted. RESULTS: CMAP failed to be recorded 1 week later. The wave amplitude of the nerve at the affected side increased along with time, however, the CMAP wave amplitudes of the affected side were all significantly lower than those of the healthy side (all P < 0.05). The SNAP wave amplitudes of the medium nerve of both sides increased along with the time. The SNAP levels 4 and 8 weeks later of the affected side were both lower than those of the healthy side (both P < 0.05). The number of modulated fibers of the medium nerve increased along with the time, however, the number of the affected side were significantly lower than those of the healthy side (all P < 0.05). Electron microscopy showed degeneration of medulla in bilateral medium nerves 1 week later, and newborn modulated fibers began to be seen since 2 weeks later. However, there were a greater number and more complete structure in the healthy side in comparison with the affected side. The wet weights of bilateral superior digital flexor muscles decreased 2 weeks later and then began to increase gradually. However, the wet weight 4 and 8 weeks later were significantly greater in the healthy side then in the affected side (both P < 0.05). CONCLUSION: Resection of sympathetic nerve is advantageous on nerve regeneration.

[Early microsurgical treatment of upper obstetrical brachial plexus injury].

OBJECTIVE: To search for the operation timing and methods for obstetrical brachial plexus injury (OBPI). METHODS: Thirty-two children with upper OBPI were treated by microsurgical procedure from October 1997 to April 2001. The average age of patients was 10 months, ranged from 3 months to 24 months; of them, 19 were below 6 months while 13 were over 6 months. Surgical procedure included neurolysis(n = 12), coaptation after resection of the neuroma without function (n = 7), phrenic nerve transfer to anterior cord of upper trunk or musculocutaneous nerve (n = 7) and intercostal nerves transfer to musculocutaneous nerve(n = 6). The children underwent operation with microsurgical technique and 7/0 or 9/0 nylon was used for nerve suture. RESULTS: Thirty cases were followed up for 21 months postoperatively; the excellent and good rate was 76.7% (23/30). The results of the children under 6 months were better than those over 6 months. CONCLUSION: The microsurgical operation might be considered at the age of 3-6 month infants who had shown little or no improvement in elbow flexion. Neurolysis and nerve coaptation are superior to neurotization. The appropriate procedure should be selected according to the findings of exploration.