Free functioning gracilis transfer for brachial plexus reconstruction using the internal mammary vessels as recipients: A case report.

Adult brachial plexus injuries are often associated with concomitant trauma to the axillary or subclavian vessels. In patients planned for free functioning gracilis transfer (FFGT) this poses a challenge to reconstructive surgeons where using the standard donor vessels can lead to endangering the circulation in the affected extremity or risk flap loss due to the poor perfusion pressures. This case report describes the use of a FFGT for upper limb reconstruction in a 22-year-old patient with a pan plexus injury and concomitant axillary artery injury following a high energy motorcycle accident. Ipsilateral internal mammary vessels were used as donor vessels after removing the 3rd and 4th costal cartilages. The gracilis muscle was harvested in its whole length, including a small transverse skin paddle, and transferred to the upper extremity. It was secured to the clavicle proximally, weaved into the Flexor Digitorum Profundus tendons distally and neurotised by the spinal accessory nerve. The procedure and postoperative course were uneventful and the follow up at 18 months showed MRC grade 4 in elbow flexion with only a slight contour deformity at the donor chest site. This is the first report demonstrating the use of internal mammary vessels for FFGT reconstruction in the upper extremity after removing two costal cartilages to achieve sufficient pedicle length.

Service reconfiguration in the department of hand surgery during the UK COVID-19 lockdown: Birmingham experience.

In early 2020, the COVID-19 pandemic swept through the UK and had a major impact on healthcare services. The Birmingham hand centre, one of the largest hand trauma units in the country, underwent a dramatic service reconfiguration to enable robust and safe provision of care that would withstand the peak of the pandemic. Streamlining our service significantly reduced patient footfall and hospital admission while preventing intra-hospital viral transmission. Many of the changes implemented have been kept as permanent adjustments to our practice as this new model of care yields higher patient satisfaction and efficacy to withstand the pressures of further peaks in the pandemic.

Wide-awake local anaesthesia no tourniquet (WALANT) vs regional or general anaesthesia for flexor tendon repair in adults: protocol for a systematic review and meta-analysis.

BACKGROUND: Flexor tendon injuries most commonly occur following a penetrating injury to the hand or wrist. These are challenging injuries and the standard treatment is surgical repair under general or regional anaesthesia. 'Wide-awake' surgery is an emerging technique in hand surgery where a conscious patient is operated on under local anaesthetic. The vasoconstrictive effect of adrenaline (epinephrine) creates a 'bloodless' operating field and a tourniquet is not required. The potential advantages include intra-operative testing of the repair; removal of the risks of general anaesthesia; reduced costs; no aerosol generation from intubation therefore reduced risk of COVID-19 spread to healthcare professionals. The aim of this study will be to systematically evaluate the evidence to determine if wide-awake surgery is superior to general/regional anaesthetic in adults who undergo flexor tendon repair. METHODS: We designed and registered a study protocol for a systematic review and meta-analysis of comparative and non-comparative studies. The primary outcome will be functional active range of motion. Secondary outcomes will be complications, resource use (operative time) and patient-reported outcome measures. A comprehensive literature search will be conducted (from 1946 to present) in MEDLINE, EMBASE, CINAHL, and Cochrane Library. Grey literature will be identified through Open Grey, dissertation databases and clinical trials registers. All studies on wide-awake surgery for flexor tendon repair will be included. The comparator will be general or regional anaesthesia. No limitations will be imposed on peer review status or language of publication. Two investigators will independently screen all citations, full-text articles and abstract data. Potential conflicts will be resolved through discussion or referral to a third author when necessary. The study methodological quality (or bias) will be appraised using an appropriate tool. If feasible, we will conduct a random effects meta-analysis. DISCUSSION: This systematic review will summarise the best available evidence and definitively establish if function, complications, cost, or patient-reported outcomes are improved when flexor tendons are repaired using wide-awake technique. It will determine if this novel approach is superior to general or regional anaesthesia. This knowledge will help guide hand surgeons by continuing to improve outcomes from flexor tendon injuries. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020182196.

Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children.

The purpose of this study was to evaluate long-term outcomes of the free functioning gracilis transfer in children with traumatic total brachial plexus palsy. We used the free functioning gracilis transfer to reconstruct elbow flexion and prehension in 17 children with a mean age of 13.4 years (range 3-17) who were followed-up over a mean period of 6 years (range 2-16). The transferred gracilis delivered a stable elbow flexion with a useful power, as well as reconstructed active finger motion. In 3-11-year-old patients we noted a tendency towards developing a progressive flexion contracture of the elbow. The limb length discrepancy observed in our patients was not different from the brachial plexus palsy patients treated without the free functioning gracilis transfer. In conclusion, the free functioning gracilis transfer is a reliable reconstructive technique for reanimating upper extremity in children of all ages capable of delivering stable function over a long period of time. LEVEL OF EVIDENCE: IV.

Analysis of shoulder abduction by dynamic shoulder radiograph following suprascapular nerve repair in brachial plexus injury.

BACKGROUND: Suprascapular nerve repair is a widely-prioritized procedure for shoulder reconstruction following brachial plexus injury. Although this procedure only reconstructs glenohumeral joint motion, the standard clinical assessment of shoulder function also includes the scapulothoracic joint contribution. The purpose of this preliminary study was to develop an objective method to accurately analyze shoulder abduction following suprascapular nerve repair in brachial plexus injury patients. METHODS: We introduced an objective method to accurately analyze independent shoulder abduction performed by supraspinatus muscle with the help of dynamic shoulder radiography. Antero-posterior radiographs of both shoulders in adduction and maximal active abduction were obtained. Five parameters were measured. They included global abduction, abduction in glenohumeral, scapulothoracic and clavicular joints along with lateral flexion of thoracic spine. Data were analyzed to distinguish glenohumeral joint contribution from that of scapulothoracic motion. The detailed biomechanics of glenohumeral motion were also analyzed in relation to scapulothoracic motion to separately define the contribution of each in global shoulder abduction. RESULTS: The test-retest, intra-examiner and inter-examiner reliabilities of the measurements were assessed. Intra-class correlation coefficient, Bland-Altman plots and repeatability coefficients showed excellent reliability for each parameter. The range of glenohumeral abduction showed high correlation to subtraction of the range of scapulothoracic from the range of global abduction. However, not all negative ranges of glenohumeral abduction meant non-recovery after nerve repair, because scapulothoracic motion contributed in parallel but not uniformly to global shoulder motion. CONCLUSION: The conventional measurement of shoulder global abduction with goniometer is not an appropriate method to analyze the results of suprascapular nerve repair in brachial plexus palsy patients. We recommend examination of glenohumeral and scapulothoracic motions separately with dynamic shoulder radiographic analysis. With scapulothoracic contribution to the global shoulder motion, the glenohumeral motion can be wrongly assessed.

Bifid Median Nerve--A Case Report.

A wide variety of anatomic variations of the median nerve at wrist have been reported and the awareness of these variations are essential for the surgeon treating carpal tunnel pathologies to avoid inadvertent injury to the nerve during surgery. We report a rare case of bifid median nerve accompanied by a persistent median artery found incidentally in a patient who underwent flexor tendon reconstruction for subcutaneous tendon rupture. The current literature regarding the anomaly is reviewed and surgically relevant aspects are discussed.

Differentiated adipose-derived stem cells promote myelination and enhance functional recovery in a rat model of chronic denervation.

Transplantation of autologous Schwann cells (SCs) is a promising approach for treating various peripheral nerve disorders, including chronic denervation. However, given their drawbacks, such as invasive biopsy and lengthy culture in vitro, alternative cell sources would be needed. Adipose-derived stem cells (ASCs) are a candidate, and in this study rat ASCs transdifferentiated into a SC phenotype (dASC) cocultured with dorsal root ganglion neurons were shown to associate with neurites and to express myelin basic protein (MBP)-positive myelin protein. Furthermore, dASCs transplanted into a chronically denervated rat common peroneal nerve survived for at least for 10 weeks, maintaining their differentiated state. Immunohistochemical analysis revealed that transplanted dASCs associated with regenerating axons, forming MBP-/protein zero-positive myelin sheaths. The cell survival and myelin expression assessed by double labelling with S100 and glial fibrillary acidic protein were similar between the dASC- and SC-transplanted nerves. Importantly, transplantation of dASCs resulted in dramatically improved motor functional recovery and nerve regeneration, with a level comparable to, or even superior to, transplantation of SCs. In conclusion, dASCs are capable of myelinating axons in vivo and enhancing functional outcome after chronic denervation.

Ibuprofen improves functional outcome after axotomy and immediate repair in the peripheral nervous system.

BACKGROUND: Activation of the Small GTP-binding protein Rho following the nerve injury contributes to the lack of regeneration in the peripheral nervous system. By elucidating the mechanisms leading to Rho activation, a nonsteroidal anti-inflammatory drug ibuprofen has been identified as a potent inhibitor of Rho activity. In this study we tested the hypothesis, that inhibiting Rho activity by ibuprofen will enhance posttraumatic regeneration after peripheral nerve injury. METHODS: In adult female Wistar rats we introduced an experimental injury by excising a 5 mm piece of the tibial nerve and returning it to the injury site as an interpositional graft. The animals then received ibuprofen or phosphate buffered saline through an osmotic pump for a period of 3 weeks. Following the injury we recorded tibial functional index (TFI) on a weekly basis. After 3 months we measured nerve conduction velocity and peak amplitude of action potential (PAAP). Also, the histomorphometric analysis was carried out in the zone distal to the injury site. RESULTS: We found that the animals receiving ibuprofen recovered the tibial nerve function more rapidly, with the TFI being significantly different 8, 9, 11 and 12 weeks after the injury. We also detected the values of the PAAP, the area of axons and the area of myelin to be significantly greater in the experimental group. CONCLUSIONS: Our results show that ibuprofen significantly enhanced regeneration after tibial nerve axotomy and repair in rats. This study is expected to set a stage for testing the ibuprofen in the human patients.

The Rho-associated kinase inhibitor fasudil hydrochloride enhances neural regeneration after axotomy in the peripheral nervous system.

BACKGROUND: The Rho family of small GTPases is responsible for various processes involving actin cytoskeleton in eukaryotic cells, including neurite outgrowth. Several substances found at the peripheral nerve injury site were shown to activate one member of this family, Rho. The activation of Rho leads to neurite outgrowth inhibition and the development of posttraumatic neuropathic pain. The authors used the clinically tested Rho-associated kinase inhibitor fasudil hydrochloride to enhance the functional recovery of the peripheral nerve in the rat. METHODS: In the peroneal nerve interpositional graft model, the authors administered fasudil (experimental groups) or saline (control groups) (1) intraperitoneally and (2) directly into the graft by microinjection (n = 6 animals per experimental condition). Neural recovery was assessed during postoperative follow-up lasting 80 days by peroneal functional index, electrophysiologic, and histomorphometric analyses. RESULTS: The peroneal functional index returned to values not significantly different from preoperative values on days 55 (fasudil injected into the graft) and 60 (fasudil injected intraperitoneally) in the experimental groups. In the control groups, this took 70 (saline injected intraperitoneally) and 75 days (saline injected into the graft). These results are supported by electrophysiologic and histomorphologic assessments. CONCLUSIONS: The authors determined that fasudil hydrochloride was capable of accelerating the functional regeneration after peripheral nerve axotomy, which is consistent with the results of reports about Rho cascade disruption in the central nervous system. Because fasudil hydrochloride is a clinically tested drug, it could be used to enhance neural regeneration in human patients as well.

Use of calcium phosphate cement paste in orbital volume augmentation.

BACKGROUND: The development of calcium phosphate in cement paste form has made its application simplified and easy. In this study, the authors used an alpha-tricalcium phosphate/dicalcium phosphate dibasic/tetracalcium phosphate monoxide/hydroxyapatite injectable calcium phosphate cement paste to evaluate its potential use in orbital volume augmentation. METHODS: Five New Zealand white rabbits were used in this study. In each rabbit, the right orbit was directly implanted with calcium phosphate cement in its injectable paste form, and a prehardened form was placed in the left orbit. The orbital roof was approached through a subciliary skin incision and the implant was placed posterior to the globe of the eyeball to push it outward. Measurement of proptosis and intraocular pressure was monitored before and after implantation. The animals were killed after 3 months, and orbit bone-implant samples were taken for histology and microradiography. RESULTS: In both groups, proptosis was induced, 4.2 +/- 0.27 mm in the prehardened group and 3.8 +/- 0.22 mm in the injectable group. These values taken 1 week postimplantation were unchanged until the end of the experiment and were maintained without significant intraocular pressure changes. The implants were well tolerated, and no sign of infection, extrusion, or migration was noted. Histologic analysis showed good biocompatibility and osteoconductivity, and microradiography has confirmed a well-set cement with direct bone union to it. CONCLUSION: These findings therefore indicate that calcium phosphate cement implant, when used as an injectable paste or in its prehardened form, can be a safe, effective material for orbital volume augmentation.

p21Cip1/WAF1 regulates radial axon growth and enhances motor functional recovery in the injured peripheral nervous system.

Recent studies have provided evidence that p21Cip1/WAF1 has not only cell cycle-associated activities but also other biological activities like neurite elongation. To investigate the role of p21Cip1/WAF1 in the in vivo axonal regeneration in the peripheral nervous system, we developed a p21Cip1/WAF1 knockout (KO) mice sciatic nerve injury model. We performed quantitative assessments of the functional, histological, and electrophysiological recoveries after sciatic nerve injury in p21Cip1/WAF1 KO mice and compared the results with those of the wild-type mice. p21Cip1/WAF1 KO mice showed a significant delay of the motor functional recovery between 21 and 42 days after sciatic nerve injury. The values of motor conduction velocity in p21Cip1/WAF1 KO mice were significantly lower than those in the wild-type mice on postoperative day 28. The mean percent neural tissue and the mean nerve axon width of p21Cip1/WAF1 KO mice were significantly less than those of the wild-type mice, which was caused by hyperphosphorylation of neurofilaments. Therefore, p21Cip1/WAF1 was considered to be involved in radial axon growth and to be essential for the motor functional recovery following peripheral nervous system injury.

A simple method for auricular reconstruction in mild cases of conchal type microtia.

The authors describe their method of helix/antihelix creation together with their algorithm of mild conchal type microtia treatment. In mild cases of conchal type microtia, they do not use a platform-based framework but fabricate the helix and the antihelix separately from costal cartilage and anchor them firmly into the corrected remnant concha. A framework created in this way is sufficiently supportive for the new ear, has good aesthetic features, and is fast and easy to fabricate. Moreover, because the procedure does not require a large amount of cartilage, it also decreases the occurrence of donor-site complications. The authors present a group of 45 patients with a total of 47 reconstructed ears and follow-up periods of from 6 months to 6 years.

Activation of Rho in the injured axons following spinal cord injury.

Axons of the adult central nervous system have very limited ability to regenerate after injury. This inability may be, at least partly, attributable to myelin-derived proteins, such as myelin-associated glycoprotein, Nogo and oligodendrocyte myelin glycoprotein. Recent evidence suggests that these proteins inhibit neurite outgrowth by activation of Rho through the neurotrophin receptor p75(NTR)/Nogo receptor complex. Despite rapidly growing knowledge on these signals at the molecular level, it remained to be determined whether Rho is activated after injury to the central nervous system. To assess this question, we establish a new method to visualize endogenous Rho activity in situ. After treatment of cerebellar granular neurons with the Nogo peptide in vitro, Rho is spatially activated and colocalizes with p75(NTR). Following spinal cord injury in vivo, massive activation of Rho is observed in the injured neurites. Spatial regulation of Rho activity may be necessary for axonal regulation by the inhibitory cues.

Changes in mRNA of Slit-Robo GTPase-activating protein 2 following facial nerve transection.

Complex processes following peripheral nerve injury integrate a number of various external cues and their intracellular responses resulting in the cytoskeletal remodeling. One of these cues, Slit protein, plays an important role in neuronal migration and axonal guidance through the interaction with Roundabout (Robo) receptor. It was reported that the signal from Robo is transmitted to a specific family of GTPase-activating proteins (GAPs) named Slit-Robo GAPs. The Slit-Robo GAPs (srGAPs) further transmit the signal to the actin cytoskeleton controlling Rho GTPases and thus provide a direct link between Slit-Robo signaling and actin cytoskeleton. We examined the effects of facial nerve transection on srGAP2 mRNA expression in the facial nerve nuclei by in situ hybridization. SrGAP2 mRNA was initially expressed, and its expression increased from 3 to 28 days after transection, with the peak at the seventh day after axotomy. The upregulation was found mostly in the neuronal cells and only to a small extent in the glial cells. Our results suggest that srGAP2, as a part of Slit-Robo pathway, plays an important role in the axonal regeneration after axotomy.

FLRT3, a cell surface molecule containing LRR repeats and a FNIII domain, promotes neurite outgrowth.

The mature peripheral nervous system has the ability to survive and to regenerate its axons following axonal injury. After nerve injury, the distal axonal and myelin segment undergoes dissolution and absorption by the surrounding cellular environment, a process called Wallerian degeneration. Using cDNA microarrays, we isolated FLRT3 as one of the up-regulated genes expressed in the distal segment of the sciatic nerve 7 days after transection relative to those of the intact sciatic nerve. FLRT3 is a putative type I transmembrane protein containing 10 leucine-rich repeats, a fibronectin type III domain, and an intracellular tail. The neurons plated on CHO cells expressing FLRT3 extended significantly longer neurites than those plated on wild-type CHO cells, demonstrating that FLRT3 promotes neurite outgrowth. FLRT3 mRNA was especially abundant in the basal ganglia, the granular layer of cerebellum, and the hippocampus, except the CA1 region in the adult rat brain. Thus, FLRT3 may contribute to regeneration following axonal injury.

Expression of FERM domain including guanine nucleotide exchange factor mRNA in adult rat brain.

FERM domain including Rho GEF (FIR) belongs to Dbl family of guanine nucleotide exchange factors and specifically activates biochemical pathways specific for Rac1. FIR was shown to regulate neurite remodeling of the embryonic neurons. Here we report a distribution of FIR mRNA in adult rat brain using in situ hybridization. The expression was found all throughout the brain with the most intensive signals in hippocampus, piriform cortex, red nucleus and nuclei of cranial nerves. The signal was predominantly localized in the neuronal cells.