Comparison of Vickers' Physiolysis With Osteotomy for Primary Correction of Clinodactyly.

Background: The purpose of this study was to compare the Vickers physiolysis procedure with osteotomy for correction of digital clinodactyly and determine which method provides better correction at final follow-up or whether the patient's age, preoperative angulation, or presence of syndactyly affects final outcomes. Methods: All patients of skeletal immaturity who underwent surgical correction of clinodactyly were evaluated with clinical examination and radiographs to determine the percentage and absolute change in the degree of clinodactyly pre- versus postoperatively, in addition to stratification based on the degree of deformity, age, and presence of syndactyly. Results: Vickers' physiolysis and osteotomy were undertaken in 30 and 11 digits, respectively. The angulation significantly improved from 43.0° to 23.9°, with a 46.2% correction of deformity in the Vickers group at 46.3 months. The angulation decreased from 39.2° to 22.4° in the osteotomy group, with a 55.3% correction of deformity at 55.3 months. There was better correction in those with isolated clinodactyly compared with those with concomitant syndactyly and better percentage of correction in patients with lesser deformity in the Vickers group. There were more reoperations in the osteotomy group. Conclusions: The use of osteotomy may lead to more revision cases, whereas the Vickers procedure has minimal complications and need for revision. The Vickers physiolysis procedure is more effective in those with angulation <55°.

Rectus Abdominis Motor Nerves as Donor Option for Free Functional Muscle Transfer: A Cadaver Study and Case Series.

BACKGROUND: Current management of brachial plexus injuries includes nerve grafts and nerve transfers. However, in cases of late presentation or pan plexus injuries, free functional muscle transfers are an option to restore function. The purpose of our study was to describe and evaluate the rectus abdominis motor nerves histomorphologically and functionally as a donor nerve option for free functional muscle transfer for the reconstruction of brachial plexus injuries. METHODS: High intercostal, rectus abdominis, thoracodorsal, and medial pectoral nerves were harvested for histomorphometric analysis from 4 cadavers from levels T3-8. A retrospective chart review was performed of all free functional muscle transfers from 2001 to 2014 by a single surgeon. RESULTS: Rectus abdominis nerve branches provide a significant quantity of motor axons compared with high intercostal nerves and are comparable to the anterior branch of the thoracodorsal nerve and medial pectoral nerve branches. Clinically, the average recovery of elbow flexion was comparable to conventional donors for 2-stage muscle transfer. CONCLUSION: Rectus abdominis motor nerves have similar nerve counts to thoracodorsal, medial pectoral nerves, and significantly more than high intercostal nerves alone. The use of rectus abdominis motor nerve branches allows restoration of elbow flexion comparable to other standard donors. In cases where multiple high intercostal nerves are not available as donors (rib fractures, phrenic nerve injury), rectus abdominis nerves provide a potential option for motor reconstruction without adversely affecting respiration.

Lower Extremity Reconstruction with Free Gracilis Flaps.

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeon's armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeon's series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes, and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was ≤ 7 days in 6 patients, 8-30 days in 11 patients, 31-90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30-month follow-up. Conclusion This study demonstrates the utility of the free gracilis flap in reconstruction of small- to medium-sized defects of the lower extremity. This flap has a high success rate and a low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.

Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury.

BACKGROUND: With complete plexus injuries or late presentation, free functional muscle transfer (FFMT) becomes the primary option of functional restoration. Our purpose is to review cases over a 10-year period of free functioning gracilis muscle transfer after brachial plexus injury to evaluate the effect of different donor nerves used to reinnervate the FFMT on functional outcome. METHODS: A retrospective study from April 2001 to January 2011 of a single surgeon's practice was undertaken. During this time period 22 patients underwent FFMT at Washington University in St Louis, Missouri for elbow flexion. RESULTS: Thirteen patients for whom FFMT was performed for elbow flexion met all of the requirements for inclusion in this study. Average time from injury to first operation was 12.8 months (range 4-60), and average time from injury to FFMT was 29 months (range 8-68). Average follow-up was 31.8 months (range 11-84). The nerve donors utilized included the distal accessory nerve, intercostal with or without rectus abdominis nerves, medial pectoral nerves, thoracodorsal nerve, and flexor carpi ulnaris fascicle of ulnar nerve. Functional recovery of elbow flexion was measured using the MRC grading system which showed 1 M5/5, 5 M4, 4 M3, and 3 M2 outcomes. CONCLUSION: Intraplexal donor motor nerves if available will provide better transferred muscle function because they are higher quality donors closer to the muscle and can be done in one stage without a nerve graft. Otherwise, intercostal, rectus abdominis, or the distal accessory nerve should be used in a staged fashion. © 2016 Wiley Periodicals, Inc. Microsurgery 37:377-382, 2017.

Diagnosis and Treatment of Acute Lunotriquetral Ligament Injuries.

Isolated acute lunotriquetral (LT) injuries are an uncommon diagnosis in hand surgery. Diagnosis is aided by a high index of suspicion when pain is localized over the LT joint. Standard radiographs show typically normal findings, leading to advanced diagnostic investigations, including MRI and wrist arthroscopy. Standard treatment options for acute LT injuries include immobilization, arthroscopy, and direct open LT repair.

Pronator teres opposition transfer through Guyon's canal: a technique.

Restoration of thumb opposition in the setting of peripheral nerve or brachial plexus injury is critical to upper limb function. When commonly utilized opposition donors are unavailable for clinical use, the pronator teres represents a good and reliable tendon for restoration of thumb opposition. Here we describe our rational and technique for pronator teres opposition transfer using Guyon's canal as a pulley.

Reverse end-to-side nerve transfer: from animal model to clinical use.

PURPOSE: Functional recovery after peripheral nerve injury is predominantly influenced by time to reinnervation and number of regenerated motor axons. For nerve injuries in which incomplete regeneration is anticipated, a reverse end-to-side (RETS) nerve transfer might be useful to augment the regenerating nerve with additional axons and to more quickly reinnervate target muscle. This study evaluates the ability of peripheral nerve axons to regenerate across an RETS nerve transfer. We present a case report demonstrating its potential clinical applicability. METHODS: Thirty-six Lewis rats were randomized into 3 groups. In group 1 (negative control), the tibial nerve was transected and prevented from regenerating. In group 2 (positive control), the tibial and peroneal nerves were transected, and an end-to-end (ETE) nerve transfer was performed. In group 3 (experimental model), the tibial nerve and peroneal nerves were transected, and an RETS nerve transfer was performed between the proximal end of the peroneal nerve and the side of the denervated distal tibial stump. Nerve histomorphometry and perfused muscle mass were evaluated. Six Thy1-GFP transgenic Sprague Dawley rats, expressing green fluorescent protein in their neural tissues, also had the RETS procedure for evaluation with confocal microscopy. RESULTS: Nerve histomorphometry showed little to no regeneration in chronic denervation animals but statistically similar regeneration in ETE and RETS animals at 5 and 10 weeks. Muscle mass preservation was similar between ETE and RETS groups by 10 weeks and significantly better than negative controls at both time points. Nerve regeneration was robust across the RETS coaptation of Thy1-GFP rats by 5 weeks. CONCLUSIONS: Axonal regeneration occurs across an RETS coaptation. An RETS nerve transfer might augment motor recovery when less-than-optimal recovery is otherwise anticipated. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Two-level motor nerve transfer for the treatment of long thoracic nerve palsy.

The authors report a case of long thoracic nerve (LTN) palsy treated with two-level motor nerve transfers of a pectoral fascicle of the middle trunk, and a branch of the thoracodorsal nerve. This procedure resulted in near-total improvement of the winged scapula deformity, and a return of excellent shoulder function. A detailed account of the postoperative physical therapy regimen is included, as this critical component of the favorable result cannot be overlooked. This case establishes the two-level motor nerve transfer as a new option for treating LTN palsy, and demonstrates that nerve transfers should be considered in the therapeutic algorithm of an idiopathic mononeuritis.

Utilizing three-dimensional fluorescence's red-shift cascade effect to monitor mycobacterium PRY-1 degradation of aged petroleum.

Samples of Mycobacterium PRY-1 inoculated motor oil are subjected to three-dimensional fluorescence spectroscopy to document the shifting of excitation/emission maxima as the solutions undergo serial dilutions. Effects such as self-quenching of individual polycyclic aromatic hydrocarbons (PAHs) and energy transfer between PAHs combine to produce large red-shifts in the resulting fluorescence emission spectra. This process is repeated over a series of weeks and is compared to preceding spectra to gauge the microbial degradation of the petroleum. Results show a two-fold, or 75%, PAH contaminant degradation by Mycobacterium PRY-1 over a 140-day growth period.