Changes in Renal Anatomy After Fenestrated Endovascular Aneurysm Repair.

OBJECTIVE: To assess short- and long-term movement of renal arteries after fenestrated endovascular aortic repair (FEVAR). METHODS: Consecutive patients who underwent FEVAR at one institution with a custom-made device designed with fenestrations for the superior mesenteric (SMA) and renal arteries, a millimetric computed tomography angiography (CTA), and a minimum of 2 years' follow-up were included. Angulation between renal artery trunk and aorta, clock position of the origin of the renal arteries, distance between renal arteries and SMA, and target vessel occlusion were retrospectively collected and compared between the pre-operative, post-operative (<6 months), and last (>12 months) CTA. RESULTS: From October 2004 to January 2014, 100 patients met the inclusion criteria and 86% of imaging was available for accurate analysis. Median follow-up was 27.3 months (22.7-50.1). There were no renal occlusions. A significant change was found in the value of renal trunk angulation of both renal arteries on post-operative compared with pre-operative CTA (17° difference upward [7.5-29], p < .001), but no significant change thereafter (p = .5). Regarding renal clock positions (7.5° of change equivalent to 15 min of renal ostial movement): significant anterior change was found between post-operative and pre-operative CTA (15 min [0-30], p = .03 on the left and 15 min [15-30], p < .001 on the right), without significant change thereafter (15 min [0-30], p = .18 on the left and 15 min [0-15] on the right, p = .28). No changes were noted on the distance between renal and SMA ostia (difference of 1.65 mm [1-2.5], p = .63). CONCLUSION: The renal arteries demonstrate tolerance to permanent changes in angulation after FEVAR of approximately 17° upward trunk movement and of 15-30 min ostial movement without adverse consequences on patency after a median of more than 2 years' follow-up. The distance between the target vessels remained stable over time. These results may suggest accommodation to sizing errors and thus a compliance with off the shelf devices in favourable anatomies.

Sural nerve grafting for long defects of the femoral nerve after resection of a retroperitoneal tumour.

Most injuries to the femoral nerve are iatrogenic in origin and occur during resection of large retroperitoneal tumours. When the defect is considerable a nerve graft is mandatory to avoid tension across the suture line. We describe two cases of iatrogenic femoral nerve injury which recovered well after reconstruction with long sural nerve grafts. The probable reasons for success were that we performed the grafting soon after the injury, the patients were not too old, the nerve repairs were reinforced with fibrin glue and electrical stimulation of the quadriceps was administered to prevent muscle atrophy. Good functional results may be obtained if these conditions are satisfied even if the length of a nerve graft is more than 10 cm.

Abductor pollicis longus transfer to restore index abduction in severe cases of cubital tunnel syndrome.

Transfer of the abductor pollicis longus tendon to restore index abduction was performed simultaneously with ulnar nerve decompression in severe cases of cubital tunnel syndrome. Eighteen elbows in 18 patients were evaluated with an average follow-up period of 46 (range 12-120) months. The status of the ulnar nerve palsy was evaluated by the Yasutake's scoring method. The mean score improved from 48 points pre-operatively to 78 points at final follow-up (maximum score 100 points). Pinch strength improved from 39% of the opposite side pre-operatively to 81% finally and it reached a plateau one year postoperatively. Despite this improvement in pinch strength, atrophy of the interosseous muscle did not disappear in nine of 12 patients with a follow-up of more than two years. All patients were satisfied with the results of increased strength and stability in pinching ability. No complications occurred.

An immunohistochemical analysis of the temporal and spatial expression of growth factors FGF 1, 2 and 18, IGF 1 and 2, and TGFbeta1 during distraction osteogenesis.

Distraction osteogenesis (DO) is a well established surgical technique that generates new bone by gradual distraction of two bony segments. In this study, we investigated the temporal and spatial profile of FGF 1, 2 and 18, IGF 1 and 2, and TGFbeta1 during distraction osteogenesis using immunohistochemistry. An osteotomy was performed on the right tibia of 13 white male New Zealand rabbits. After a delay of 7 days, distraction was started at a rate of 0.25 mm/12 hrs for 3 weeks which was followed by a 3 week period of consolidation. Immunohistochemical analysis was performed on a weekly interval to determine the expression of the growth factors. Staining of all growth factors was apparent at various levels in the centre and callus region in fibroblasts and chondrocyte cells. FGF2 however, showed continued high expression in osteoblasts. Within two weeks after the end of distraction all growth factors showed a reduction in expression except for FGF18 which maintained high levels of expression (up to 100% staining) throughout the distraction and consolidation phases. The study suggests that in comparison to the other investigated growth factors, FGF18 may play in important role throughout the entire process of distraction osteogenesis.

Overview of the radiology, histology, and bone morphogenetic protein expression during distraction osteogenesis of the mandible.

INTRODUCTION: Distraction osteogenesis (DO) is a form of in vivo tissue engineering during which an osteotomy and controlled distraction are used to lengthen bone. The molecular signals that govern distraction-induced bone formation have not been fully elucidated. Specifically, the role of bone morphogenetic proteins (BMPs) in DO of the mandible remains unclear. OBJECTIVE: To characterize the radiologic and histologic evolution of newly formed bone during DO of the mandible and to relate these changes to the expression of BMPs. METHODS: Fourteen skeletally mature male rabbits were used. A distractor device was surgically applied to one side of the mandible following osteotomy. After 1 week (latency period), distraction was started at a rate of 0.25 mm every 12 hours for 3 weeks (distraction period) and was followed by a 3-week consolidation period. Two animals were sacrificed each week after surgery (weeks 1 to 7). The mandible was resected and the new bone assessed by radiography and histology. The expression of BMPs was also analyzed using immunohistochemistry. RESULTS: There was radiographic and histologic evidence of bone formation during the distraction period. By week 6, there was mature woven bone within the distraction zone. Bone morphogenetic proteins 2 and 4 were strongly expressed in osteoblasts during distraction and in chondrocytes during consolidation. The expression of BMP-7 was relatively minor. CONCLUSION: The temporal and spatial pattern of BMP expression suggests that these proteins are important mediators of mandibular DO. Understanding the expression of BMPs may facilitate the use of recombinant proteins to enhance the rate and quality of bone generation during craniofacial DO.

Influence of chronic inflammation in peripheral target tissue on recovery of crushed nerve injury.

An experimental study was performed to investigate the influence of chronic inflammation in peripheral target tissue on recovery of the sciatic nerve after crush injury. Thirty-four male Wistar rats, weighing 300-370 g were used. The sciatic nerve was crushed unilaterally with an aneurysm clip (250 gf; holding force; 5 min). One week before the operation, chronic inflammation, localized in the tibiotarsal joint of one hind limb, was produced by the intraarticular injection of complete Freund's adjuvant. The animals were divided into five groups, as follows: CIA (crush injury with ipsilateral arthritis), CCA (crush injury with contralateral arthritis), C (crush injury without arthritis), A (sham operation and ipsilateral arthritis), and S (sham operation without arthritis). Specimens for histological examination were taken from the nerve at a site 5 mm distal to the crush injury 4 weeks postoperatively. Histological study showed that the diameters of the axons in group CIA were significantly smaller than those in group CCA and those in group C. No significant differences were observed between group CCA and group C. In conclusion, peripheral nerve recovery after crush injury was suppressed by chronic inflammation in peripheral target tissue.

Comparison between partial and minimal medial epicondylectomy combined with decompression for the treatment of cubital tunnel syndrome.

We have performed minimal medial epicondylectomy for cubital tunnel syndrome since 1990 to preserve the anterior medial collateral ligament. In this study we compared surgical outcomes between partial medial epicondylectomy (14 patients) and minimal medial epicondylectomy (18 patients) combined with ulnar nerve decompression for the treatment of cubital tunnel syndrome. Mean preoperative Yasutake scores were 57 +/- 17 points (+/-SD) in the partial epicondylectomy group and 60 +/- 15 points in the minimal medial epicondylectomy group. The postoperative scores were 79 +/- 19 points and 87 +/- 10 points, respectively. Both groups had significant improvement in their Yasutake scores following medial epicondylectomy. Similar improvements in motor conduction velocity were observed. There was no significant difference in improvement of either the Yasutake scores or the motor conduction velocity between the 2 groups. Valgus instability of the elbow was significantly greater in the partial epicondylectomy group. We therefore conclude that minimal medial epicondylectomy combined with ulnar nerve decompression is an effective treatment for cubital tunnel syndrome and that a larger excision of the medial epicondyle should be avoided.

Influence of water immersion stress on peripheral nerve recovery in the rat.

An experimental study was performed to investigate the relationship between stress and peripheral nerve recovery. Male Wistar rats weighing 200-250 g were used. The sciatic nerve was crushed unilaterally with an aneurysm clip. Stress was applied by water immersion for 3 h, three times a week, from 1 week preoperatively, and continued for 6 or 8 weeks. The animals' walking tracks were measured every week to evaluate nerve function, and a sciatic functional index (SFI) was calculated. Specimens for histological examination were taken from the nerve at a site distal to the crush injury. By 3 weeks postoperatively, the SFI in the non-stress groups had recovered, but it remained at significantly lower levels in the stress groups (P < 0.01). Histological studies showed that the recovery of nerve fibers was retarded and regenerating axons were smaller in the stress groups. Peripheral nerve recovery after crush injury was suppressed by water-immersion stress.

Vascularized fibula graft for spinal fusion in severe cervical kyphosis due to neurofibromatosis.

A successful anterior spinal fusion using vascularized fibula graft in the case of a 17-year-old male with severe cervical kyphosis due to neurofibromatosis is reported. Anterior spinal fusion at C2-7 using the fibula graft was performed with spinous process wiring. The kyphosis was corrected from 85 to 38 degrees. Bony fusion was obtained in 5 months without loss of correction.

Spinal fusion using a vascularized fibular bone graft for a patient with cervical kyphosis due to neurofibromatosis.

We performed an anterior spinal fusion using a vascularized fibular bone graft combined with posterior fusion for a patient with severe cervical kyphosis due to neurofibromatosis. The kyphosis was corrected from 85 degrees preoperatively to 38 degrees postoperatively. A vascularized fibular bone graft is a useful surgical procedure in selected patients to obtain successful bony union.

Splint therapy for trigger thumb and finger in children.

Forty-three trigger thumbs and fingers in 33 children (15 boys and 18 girls, average age 2 years and 4 months) were treated using a polyethylene splint. Affected digits included 40 thumbs, one index finger, and two middle fingers. The IP joint was stabilized in maximum extension via a strap on the dorsal side. The splint was applied only at night and during day-time naps. Twenty-four digits recovered completely in an average of 10 months, seven digits improved, and two digits required surgery. Eight patients (10 digits) dropped out of treatment. Splint therapy is effective in treating trigger thumbs and fingers in children.

Developmental dislocation of the radial head.

An unusual case of developmental dislocation of the radial head is reported. A 6-year-old boy was referred for evaluation of his elbow and was diagnosed as having an anterior dislocation of the right radial head. No dislocation was present on the left. Subsequently, the left radial head dislocated anteriorly without associated trauma 1 year after the initial examination. Intraoperative findings on the right revealed the dislocation occurred during pronation of the forearm when the radius abutted the interosseous border of the ulna. Ulnar osteomy and reinstruction of the annular fragment were performed but were, not effective in preventing redislocation.