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Souza FH, Bernardino SN, Junior ABC, Martins HADL, Souza INB, Souza RNB, Azevedo-Filho HRC. Nerves transfers for functional hand recovery in traumatic lower brachial plexopathy. Surg Neurol Int 2020; 11:358. [PMID: 33194291 PMCID: PMC7655996 DOI: 10.25259/sni_218_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/05/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Distal nerve transfers are an innovative modality for the treatment of C8-T1 brachial plexus lesions. The purpose of this case series is to report the authors’ results with hand restoration function by nerve transfer in patients with lower brachial plexus injury. Methods: Three consecutive nerve transfers were performed in a series of 11 patients to restore hand function after injury to the lower brachial plexus: brachialis motor branch to anterior interosseous nerve (AIN) and supinator branch to the posterior interosseous nerve (PIN) in a first surgical procedure, and AIN to pronator quadratus branch of ulnar nerve between 4 and 6 months later. Results: In all, 11 male patients underwent 33 surgical procedures. Time between brachial plexus injury and surgery was a mean of 11 months (range 4–13 months). Postoperative follow-up ranged from 12 to 24 months. We observed recovery of M3 or better finger flexion strength (AIN) and wrist extension (PIN) in 8 of the 11 surgically treated upper limbs. These patients recovered full thumb and finger extension between 6 and 12 months of surgery, without significant loss of donor function. Conclusion: Nerve transfers represent a way of restoring volitional control of upper extremity function in patients with C8-T1 brachial plexus injury.
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Affiliation(s)
- Fernando Henrique Souza
- Department of Neurosurgery, Hospital da Restauracao, Av Agamenon Magalhaes, Recife, Pernambuco, Brazil
| | - Silvya Nery Bernardino
- Department of Neurosurgery, Hospital da Restauracao, Av Agamenon Magalhaes, Recife, Pernambuco, Brazil
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Wu F, Ng CY. Sensory Nerve Transfer for Lower Roots Brachial Plexus Injury: Superficial Radial Nerve to the Dorsal Cutaneous Branch and the Superficial Branch of the Ulnar Nerve. J Hand Microsurg 2019; 11:178-180. [PMID: 31814673 PMCID: PMC6894950 DOI: 10.1055/s-0039-1685545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 02/19/2019] [Indexed: 10/26/2022] Open
Abstract
In the treatment of brachial plexus injury to lower nerve roots, the priority is to restore motor function to the paralyzed hand. In addition, it is also important to consider sensory reconstruction, which is crucial to the optimal restoration of prehensile function. We report the surgical technique and sensory recovery of a nerve transfer in a case in which the superficial radial nerve was transferred to the dorsal cutaneous branch and the superficial branch of the ulnar nerve in a patient with C7, C8, and T1 roots injury. The nerve transfer successfully restored sensation in the ulnar one and a half digits as well as the ulnar border of the hand, with minimal donor site deficit. This technique provides a useful sensory reconstructive option in patients with brachial plexus injury to lower roots.
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Affiliation(s)
- Feiran Wu
- Upper Limb Unit, Wrightington Hospital, Wigan, United Kingdom
| | - Chye Yew Ng
- Upper Limb Unit, Wrightington Hospital, Wigan, United Kingdom
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3
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Abstract
Nerve transfer surgery involves using a working, functional nerve with an expendable or duplicated function as a donor to supply axons and restore function to an injured recipient nerve. Nerve transfers were originally popularized for the restoration of motor function in patients with peripheral nerve injuries. However, more recently, novel uses of nerve transfers have been described, including nerve transfers for sensory reinnervation, nerve transfers for spinal cord injury and stroke patients, supercharge end-to-side nerve transfers, and targeted muscle reinnervation for the prevention and treatment of postamputation neuroma pain. The uses for nerve transfers and the patient populations that can benefit from nerve transfer surgery continue to expand. Awareness about these novel uses of nerve transfers among the medical community is important in order to facilitate evaluation and treatment of these patients by peripheral nerve specialists. A lack of knowledge of these techniques continues to be a major barrier to more widespread implementation.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, Stanford University, 300 Pasteur Drive, R293, Stanford, California, 94305, USA.
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4
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Srikanth R, Rayidi KR, Kakumanu S. Brachioradialis to flexor digitorum profundus tendon transfer to restore finger flexion. Indian J Plast Surg 2018; 51:123-130. [PMID: 30505081 PMCID: PMC6219348 DOI: 10.4103/ijps.ijps_7_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction: The main deformity following an adult lower brachial plexus injury is the loss of finger flexion. Distal nerve transfers have been used to restore finger and thumb flexion followed by tendon transfers for intrinsic replacement for opening of the fingers. When patients present beyond 6 months, only tendon transfers are applicable. Since the brachioradialis (BR) is always spared in such injuries, it is the ideal muscle to provide finger flexion. Wrist extensor power may not be normal for the use of the radial wrist extensor to serve as donor. BR to FDP transfer provides reasonable flexion range and an acceptable hand function to permit activities of daily living, when associated with ancillary procedures like opponensplasty, PIPJ arthrodesis. Materials and Methods: Eleven patients underwent a BR to FDP tendon transfer between January 2013 and January 2017 of which eight patients came for follow-up. Results: Four of the eight patients got a functionally useful hand to carry out activities of daily living with hook grip, span grasp, key pinch, chuck grip and pulp pinch. These patients also underwent simultaneous or secondary ancillary procedures. Four of the patients need secondary procedures to further improve functionality of the hand inspite of having a flexion range. Conclusion: The BR is an effective donor in providing adequate range and power of finger flexion in lower plexus injuries.
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Affiliation(s)
- R Srikanth
- Department of Plastic and Reconstructive Surgery, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Koteswara Rao Rayidi
- Department of Plastic and Reconstructive Surgery, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
| | - Subha Kakumanu
- Department of Plastic and Reconstructive Surgery, Nizams Institute of Medical Sciences, Hyderabad, Telangana, India
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Zhang L, Zhang CL, Dong Z, Gu YD. Outcome of Finger Extension After Nerve Transfer to Repair C7-T1 Brachial Plexus Palsy in Rats: Comparative Study of the Supinator Motor Branch Transfer to the Posterior Interosseous Nerve and the Contralateral C7 Transfer to the Lower Trunk. Neurosurgery 2017; 80:627-634. [PMID: 28362931 DOI: 10.1093/neuros/nyw160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Accepted: 02/22/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Functional recovery following supinator motor branch transfer requires further investigation. OBJECTIVE To compare the outcome of finger extension after supinator motor branch transfer or contralateral C7 (cC7) transfer in C7-T1 brachial plexus palsies in rats. METHODS In this study, 120 adult rats underwent C7-T1 nerve root avulsion and received different nerve transfer repairs: group A, cC7 nerve transfer to the lower trunk; group B, supinator motor branch nerve transfer to the posterior interosseous nerve (PIN); and group C, no repair. The ethology of the rats, latency and amplitude of the compound muscle action potential from the PIN, muscle mass and muscle fiber cross-sectional area of the extensor digitorum communis and extensor carpi ulnaris, and number of myelinated nerve fibers in the PIN were examined postoperatively. RESULTS There was no finger extension in group C. We observed finger extension in groups A and B 50.2 ± 5.66 and 13.1 ± 2.08 days postoperatively, respectively. Finger extension restoration in group B was greater than that in group A at 4, 8, and 12 weeks postoperatively ( P < .05). Sixteen weeks after surgery, the recovery rate of the myelinated nerve fibers in group A was marginally higher than that in group B, but the difference was not significant. Of the other measured values, group B showed a greater and significant improvement compared to group A ( P < .05). CONCLUSION Supinator motor branch transfer allows for faster recovery and is a more effective procedure for restoring finger extension in C7-T1 brachial plexus palsies.
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Affiliation(s)
- Lei Zhang
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Chun-Lin Zhang
- Department of Orthopedics, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, China
| | - Zhen Dong
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Yu-Dong Gu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China
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Nicoson MC, Franco MJ, Tung TH. Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury. Microsurgery 2016; 37:377-382. [PMID: 27704606 DOI: 10.1002/micr.30120] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Revised: 09/06/2016] [Accepted: 09/16/2016] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
| | - Michael J Franco
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Thomas H Tung
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
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Xu B, Dong Z, Zhang CG, Gu YD. Transfer of the radial branch of the superficial radial nerve to the sensory branch of the ulnar nerve for sensory restoration after C7-T1 brachial plexus injury. J Plast Reconstr Aesthet Surg 2016; 69:318-22. [DOI: 10.1016/j.bjps.2015.10.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 10/19/2015] [Accepted: 10/25/2015] [Indexed: 10/22/2022]
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Abstract
Management of brachial plexus injury is a demanding field of hand and upper extremity surgery. With currently available microsurgical techniques, functional gains are rewarding in upper plexus injuries. However, treatment options in the management of flail and anaesthetic limb are still evolving. Last three decades have witnessed significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in the diagnostic modalities, incorporation of intra-operative nerve stimulation techniques, more liberal use of nerve grafts in bridging nerve gaps, and the addition of new nerve transfers, which selectively neurotise the target muscles close to the motor end plates. Newer research works on the use of nerve allografts and immune modulators (FK 506) are under evaluation in further improving the results in nerve reconstruction. Direct reimplantation of avulsed spinal nerve roots into the spinal cord is another area of research in brachial plexus reconstruction.
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Affiliation(s)
- Prem Singh Bhandari
- Department of Plastic Surgery, Command Hospital (NC), Panchkula, Haryana, India
| | - Sanjay Maurya
- Command Hospital (WC), Chandimandir Cantt, Panchkula, Haryana, India
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Zhang CG, Dong Z, Gu YD. Restoration of hand function in C7-T1 brachial plexus palsies using a staged approach with nerve and tendon transfer. J Neurosurg 2014; 121:1264-70. [PMID: 25170672 DOI: 10.3171/2014.7.jns13594] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Brachial plexus palsies of C7-T1 result in the complete loss of hand function, including finger and thumb flexion and extension as well as intrinsic muscle function. The task of reanimating such a hand remains challenging, and so far there has been no reliable neurological reconstructive method for restoring hand function. The authors aimed to establish a reliable strategy to reanimate the paralyzed hand. Two patients had sustained C7-T1 complete lesions. In the first stage of the operative procedure, a supinator motor branch to posterior interosseous nerve transfer was performed with brachialis motor branch transfer to the median nerve to restore finger and thumb extension and flexion. In the second stage, the intact brachioradialis muscle was used for abductorplasty to restore thumb opposition. Both patients regained good finger extension and flexion. Thumb opposition was also attained, and overall hand function was satisfactory. The described strategy proved effective and reliable in restoring hand function after C7-T1 brachial plexus palsies.
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Affiliation(s)
- Cheng-Gang Zhang
- Department of Hand Surgery, Huashan Hospital, Fudan University Medical Center
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Treatment options for brachial plexus injuries. ISRN ORTHOPEDICS 2014; 2014:314137. [PMID: 24967125 PMCID: PMC4045367 DOI: 10.1155/2014/314137] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/08/2014] [Indexed: 11/18/2022]
Abstract
The incidence of brachial plexus injuries is rapidly growing due to the increasing number of high-speed motor-vehicle accidents. These are devastating injuries leading to significant functional impairment of the patients. The purpose of this review paper is to present the available options for conservative and operative treatment and discuss the correct timing of intervention. Reported outcomes of current management and future prospects are also analysed.
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Lykissas MG, Kostas-Agnantis IP, Korompilias AV, Vekris MD, Beris AE. Use of intercostal nerves for different target neurotization in brachial plexus reconstruction. World J Orthop 2013; 4:107-111. [PMID: 23878776 PMCID: PMC3717241 DOI: 10.5312/wjo.v4.i3.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2013] [Revised: 05/03/2013] [Accepted: 06/10/2013] [Indexed: 02/06/2023] Open
Abstract
Intercostal nerve transfer is a valuable procedure in devastating plexopathies. Intercostal nerves are a very good choice for elbow flexion or extension and shoulder abduction when the intraplexus donor nerves are not available. The best results are obtained in obstetric brachial plexus palsy patients, when direct nerve transfer is performed within six months from the injury. Unlike the adult posttraumatic patients after median and ulnar nerve neurotization with intercostal nerves, almost all obstetric brachial plexus palsy patients achieve protective sensation in the hand and some of them achieve active wrist and finger flexion. Use in combination with proper muscles, intercostal nerve transfer can yield adequate power to the paretic upper limb. Reinnervation of native muscles (i.e., latissimus dorsi) should always be sought as they can successfully be transferred later on for further functional restoration.
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12
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Soldado F, Bertelli J. Free gracilis transfer reinnervated by the nerve to the supinator for the reconstruction of finger and thumb extension in longstanding C7-T1 brachial plexus root avulsion. J Hand Surg Am 2013; 38:941-6. [PMID: 23566721 DOI: 10.1016/j.jhsa.2013.02.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2012] [Revised: 02/06/2013] [Accepted: 02/07/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the clinical results of a free gracilis muscle transfer to finger and thumb extensors reinnervated by supinator muscle motor branches in patients with longstanding C7-T1 root avulsion. METHODS Between January 2010 and January 2011, 3 young adult patients with traumatic C7-T1 brachial plexus palsies had gracilis transfer to the thumb and finger extensors at a mean of 38 months after injury. The muscle flap was connected to radial vessels and comitant veins and to nerve branches supplying the supinator muscle. RESULTS All patients had recovery of active thumb and finger extension, scoring M3 and M4 on the Medical Research Council scale, respectively, at a mean of 12 months after surgery. CONCLUSIONS Reconstruction of finger and thumb extension in lower-type brachial plexus injuries is a challenging problem that is most commonly addressed with an extensor tenodesis technique, which depends on wrist flexion. Free gracilis transfer innervated by nerve branches to the supinator provided the restoration of thumb and finger extension independent of wrist flexion. CLINICAL RELEVANCE For those patients with lower brachial root injury more than a year old, transfer of a free functional gracilis muscle is an alternative for the reconstruction of thumb and finger extension. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Francisco Soldado
- Pediatric Upper Extremity Surgery and Microsurgery Department, Universitat Autonoma de Barcelona, Barcelona, Spain.
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Nath RK, Benyahia M, Somasundaram C. Finger movement at birth in brachial plexus birth palsy. World J Orthop 2013; 4:24-28. [PMID: 23362472 PMCID: PMC3557319 DOI: 10.5312/wjo.v4.i1.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 10/20/2012] [Accepted: 12/17/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury.
METHODS: We conducted a retrospective study reviewing pre-surgical records of 87 patients with residual obstetric brachial plexus palsy in study 1. Posterior subluxation of the humeral head (PHHA), and glenoid retroversion were measured from computed tomography or Magnetic resonance imaging, and correlated with the finger movement at birth. The study 2 consisted of 141 obstetric brachial plexus injury patients, who underwent primary surgeries and/or secondary surgery at the Texas Nerve and Paralysis Institute. Information regarding finger movement was obtained from the patient’s parent or guardian during the initial evaluation.
RESULTS: Among 87 patients, 9 (10.3%) patients who lacked finger movement at birth had a PHHA > 40%, and glenoid retroversion < -12°, whereas only 1 patient (1.1%) with finger movement had a PHHA > 40%, and retroversion < -8° in study 1. The improvement in glenohumeral deformity (PHHA, 31.8% ± 14.3%; and glenoid retroversion 22.0°± 15.0°) was significantly higher in patients, who have not had any primary surgeries and had finger movement at birth (group 1), when compared to those patients, who had primary surgeries (nerve and muscle surgeries), and lacked finger movement at birth (group 2), (PHHA 10.7% ± 15.8%; Version -8.0°± 8.4°, P = 0.005 and P = 0.030, respectively) in study 2. No finger movement at birth was observed in 55% of the patients in this study group.
CONCLUSION: Posterior subluxation and glenoid retroversion measurements indicated significantly severe shoulder deformities in children with finger movement at birth, in comparison with those lacked finger movement. However, the improvement after triangle tilt surgery was higher in patients who had finger movement at birth.
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Functional neuro-vascularized muscle transfer for oncological reconstruction of extremity sarcoma. Surg Oncol 2012; 21:263-8. [PMID: 22835825 DOI: 10.1016/j.suronc.2012.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2012] [Revised: 06/05/2012] [Accepted: 06/23/2012] [Indexed: 11/23/2022]
Abstract
The strategy of limb salvage following surgical resection of skeletal tumor has led to an increased demand for more complex reconstructive options in order to achieve better functional outcomes. Functional neuro-vascularized muscle transfer (FMT) is a beneficial tool for restoring joint movement involving the reconstruction of "movement" in the affected extremity. Until now, however, the clinical application of FMT was mainly limited to trauma cases and to date, very few studies have focused on musculoskeletal oncology. In this study, we reviewed patients who underwent wide resection for extremity sarcoma and functional reconstruction using FMT and discussed the advantages, indications and complications of the procedure.
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Bertelli JA. Distal sensory nerve transfers in lower-type injuries of the brachial plexus. J Hand Surg Am 2012; 37:1194-9. [PMID: 22534572 DOI: 10.1016/j.jhsa.2012.02.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 02/25/2012] [Accepted: 02/27/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE To report the results of sensory nerve transfers to reconstruct sensation on the ulnar side of the hand in lower-type palsies of the brachial plexus. METHODS From 2007 to 2009, we operated on 6 men and 2 women with a lower-type injury of the brachial plexus and observed them for a minimum of 24 months. The mean interval between the injury and surgery was 8 months (SD ± 8.6 mo). Before surgery, we documented anesthesia on the ulnar side of the hand in all patients. Donor nerves included cutaneous branches of the median nerve to the palm (n = 5) or the palmar cutaneous branch of the median nerve (n = 3). The ulnar proper digital nerve of the little finger was the recipient nerve. We evaluated sensory recovery by assessing static 2-point discrimination and sensation to Semmes-Weinstein monofilaments. RESULTS According to the British Medical Council system of evaluation, 5 patients scored S3 and 3 scored S3+. CONCLUSIONS In lower-type injuries of the brachial plexus, transfer of median nerve branches that innervate the palm of the hand to the ulnar proper digital nerve of the little finger predictably restored protective sensation on the ulnar side of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jayme A Bertelli
- Center of Biological and Health Sciences, Department of Neurosurgery, University of the South of Santa Catarina (Unisul), Tubarão, Brazil.
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16
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Abstract
Free functional muscle transfers are an excellent treatment option in patients when significant time has passed after a nerve injury. In addition, they are the treatment of choice for reconstruction of established Volkmann's ischemic contracture, muscle loss from trauma, or tumor resection, and in congenital muscle absence. In cases where there is both soft tissue and functional muscle loss, free functional muscle transfers can address these problems together. This article focuses on the key principles for functional reconstruction of the upper extremity with free functional muscle transfers.
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Affiliation(s)
- Alexander Seal
- Department of Orthopaedic Surgery, University of Southern California, USC University Hospital, LAC + USC Medical Center, 2025 Zonal Avenue, GNH 3900, Los Angeles, CA 90089-9312, USA
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Kovachevich R, Kircher MF, Wood CM, Spinner RJ, Bishop AT, Shin AY. Complications of intercostal nerve transfer for brachial plexus reconstruction. J Hand Surg Am 2010; 35:1995-2000. [PMID: 21095076 DOI: 10.1016/j.jhsa.2010.09.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 09/08/2010] [Accepted: 09/13/2010] [Indexed: 02/02/2023]
Abstract
PURPOSE Although numerous publications discuss outcomes of intercostal nerve transfer for brachial plexus injury, few publications have addressed factors associated with intercostal nerve viability or the impact perioperative nerve transfer complications have on postoperative nerve function. The purposes of this study were to report the results of perioperative intercostal nerve transfer complications and to determine whether chest wall trauma is associated with damaged or nonviable intercostal nerves. METHODS All patients who underwent intercostal nerve transfer as part of a brachial plexus reconstruction procedure as a result of injury were identified. A total of 459 nerves in 153 patients were transferred between 1989 and 2007. Most nerves were transferred for use in biceps innervation, free-functioning gracilis muscle innervation, or a combination of the two. Patient demographics, trauma mechanism, associated injuries, intraoperative nerve viability, and perioperative complications were reviewed. RESULTS Complications occurred in 23 of 153 patients. The most common complication was pleural tear during nerve elevation, occurring in 14 of 153 patients. Superficial wound infection occurred in 3 patients, whereas symptomatic pleural effusion, acute respiratory distress syndrome, and seroma formation each occurred in 2 patients. The rate of complications increased with the number of intercostal nerves transferred. Nerves were harvested from previously fractured rib levels in 50 patients. Rib fractures were not associated with an increased risk of overall complications but were associated with an increased risk of lack of nerve viability. In patients with rib fractures, intraoperative nerve stimulation revealed 148 of 161 nerves to be functional; these were subsequently transferred. In patients with preoperative ipsilateral phrenic nerve palsy, the risk of increased complications was marginally significant. CONCLUSIONS Brachial plexus reconstruction using intercostal nerves can be challenging, especially if there is antecedent chest wall trauma. Complications were associated with increasing numbers of intercostal nerves transferred. Ipsilateral rib fracture was adversely associated with intercostal nerve viability; it was not significantly associated with complication risk and should not be considered a contraindication to transfer. Preoperative phrenic nerve palsy was marginally associated with the likelihood of complications but not postoperative respiratory dysfunction when associated with intercostal nerve transfer. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Rudy Kovachevich
- Department of Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Dong Z, Gu YD, Zhang CG, Zhang L. Clinical use of supinator motor branch transfer to the posterior interosseous nerve in C7–T1 brachial plexus palsies. J Neurosurg 2010; 113:113-7. [DOI: 10.3171/2010.1.jns091441] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
In C7–T1 brachial plexus palsies, finger extension and flexion are absent. At the authors' institution, finger flexion has been successfully reconstructed by transferring the brachialis motor branch to the anterior interosseous nerve. However, there is no reliable method for restoring finger extension. In the present study, the authors examined the surgical results of transferring the supinator motor branch to the posterior interosseous nerve.
Methods
Since October 2007, the authors have performed a supinator motor branch transfer to the posterior interosseous nerve in 4 patients. The patients underwent follow-up every 3–4 months postoperatively.
Results
Finger extension appeared between 5 and 9 months in the first 3 cases and demonstrated promising improvement over time. One recent case remains under follow-up.
Conclusions
A supinator motor branch to posterior interosseous nerve transfer leads to reliable recovery of thumb and finger extension. Therefore, it is a viable option for C7–T1 brachial plexus palsies.
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19
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Berger A, Hierner R. Freie funktionelle Transplantation des Musculus gracilis zur Wiederherstellung der Ellbogenbeugung bei posttraumatischen Armplexusschäden. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2009; 21:141-56. [PMID: 19685224 DOI: 10.1007/s00064-009-1704-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alfred Berger
- Klinik für Plastische, Hand- und Wiederherstellungschirurgie, Schwerverbranntenzentrum der Medizinischen Hochschule Hannover, Hannover, Germany
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20
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Carlsen BT, Bishop AT, Shin AY. Late reconstruction for brachial plexus injury. Neurosurg Clin N Am 2009; 20:51-64, vi. [PMID: 19064179 DOI: 10.1016/j.nec.2008.07.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Traumatic brachial plexus injuries are devastating and management is complex. Treatment involves a multidisciplinary approach. Primary reconstruction involves nerve repair, grafting, and transfer techniques. Secondary reconstruction includes microneurovascular free-functioning muscle transfer, tendon transfers, and arthrodesis to improve or restore function. These procedures are indicated when patients present more than 12 months from injury or when primary reconstruction procedures fail, and should focus on elbow flexion and shoulder stability. A free-functioning muscle transfer is often indicated for elbow flexion, with double free-functioning muscle transfers providing possible prehension. Shoulder reconstruction focuses on restoring stability to the glenohumeral joint and restoring abduction. This article outlines these techniques, their principles, and important details.
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Affiliation(s)
- Brian T Carlsen
- Mayo Clinic, Division of Hand Surgery, Rochester, MN 55905, USA
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21
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Bengtson KA, Spinner RJ, Bishop AT, Kaufman KR, Coleman-Wood K, Kircher MF, Shin AY. Measuring outcomes in adult brachial plexus reconstruction. Hand Clin 2008; 24:401-15, vi. [PMID: 18928889 DOI: 10.1016/j.hcl.2008.04.001] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The focus of this article is on evaluating the various outcome measures of surgical interventions for adult brachial plexus injuries. From a surgeon's perspective, the goals of surgery have largely focused on the return of motor function and restoration of protective sensation. From a patient's perspective, alleviation of pain, cosmesis, return to work, and emotional state are also important. The ideal outcome measure should be valid, reliable, responsive, unbiased, appropriate, and easy. The author outlines pitfalls and benefits of current outcome measures and offers thoughts on possible future measures.
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Affiliation(s)
- Keith A Bengtson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA
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22
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Soucacos PN, Vekris MD, Zoubos AB, Johnson EO. Secondary reanimation procedures in late obstetrical brachial plexus palsy patients. Microsurgery 2006; 26:343-51. [PMID: 16628747 DOI: 10.1002/micr.20249] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The varying degrees of spontaneous reinnervation that occur in untreated obstetrical brachial plexus palsy leave characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Early microsurgical reconstruction of the affected plexus leads to a more rewarding overall function of the upper arm, but residual deformities might appear later which are similar, although less serious, than those observed in untreated cases. Secondary procedures of the shoulder, elbow, forearm, and hand will improve the appearance and function of the upper extremity in late cases of obstetrical brachial plexus. Careful preoperative planning is mandatory and a multistage approach should be applied, depending on the type of palsy and the age of the patient.
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Affiliation(s)
- Panayotis N Soucacos
- Department of Orthopedic Surgery, School of Medicine, University of Athens, Athens, Greece.
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23
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Abstract
Adult traumatic brachial plexus injuries are devastating, and they are occurring with increasing frequency. Patient evaluation consists of a focused assessment of upper extremity sensory and motor function, radiologic studies, and, most important, preoperative and intraoperative electrodiagnostic studies. The critical concepts in surgical treatment are patient selection as well as the timing and prioritizing of restoration of function. Surgical techniques include neurolysis, nerve grafting, neurotization, and free muscle transfer. Results are variable, but increased knowledge of nerve injury and repair, as well as advances in microsurgical techniques, allow not only restoration of elbow flexion and shoulder abduction but also of useful prehension of the hand in some patients.
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Affiliation(s)
- Alexander Y Shin
- Department of Orthopaedic Surgery, Division of Hand Surgery, Mayo Clinic, Rochester, MN 55905, USA
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24
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Abstract
Functioning free-muscle transfers are now an important, even essential, tool in the current management of patients with brachial plexus injury. They are indicated for the restoration of elbow flexion in patients who delay presentation(those seen after 6 to 9 mo). Double free-muscle transfers provide the possibility of simple grasp function when combined with nerve transfers or grafts for restoration of shoulder motion, hand sensation, and triceps function.
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Affiliation(s)
- Allen T Bishop
- Division of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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25
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Irie H, Kato T, Ikebe K, Tsuchida T, Oniki Y, Takagi K. Antioxidant effect of MCI-186, a new Free-Radical scavenger, on ischemia-reperfusion injury in a rat hindlimb amputation model. J Surg Res 2004; 120:312-9. [PMID: 15234228 DOI: 10.1016/j.jss.2003.12.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2003] [Indexed: 10/26/2022]
Abstract
BACKGROUND A newly synthesized free-radical scavenger, MCI-186 (3-methyl-1-phenyl-2-pyrazolin-5-1), was recently approved in Japan for treating acute brain infarction. The purpose of this study was to investigate whether or not MCI-186 is effective in reducing ischemia-reperfusion injury in the extremities. MATERIALS AND METHODS Warm ischemia was sustained for 4 hours. The animals were divided into 4 groups: (1) sham group, (2) control group (saline injection), (3) MCI group (MCI-186 injection), and (4) EPC group (EPC-K1 [(l-ascorbic acid 2-[3,4-dihydro-2, 5,7,8-tetramethyl-2-(4,8,12-trimethyltridecyl)-2H-1-benzopyran-6-yl hydrogen phosphate] potassium salt], a hydroxyl-radical scavenger, injection). Wet and dry (W/D) weights of the gastrocnemius and tibialis anterior muscles, muscle contractile function, and serum levels of creatine phosphokinase (CPK), lactate dehydrogenase (LDH), glutamic oxaloacetic transminase (GOT), and mitochondrial glutamic oxaloacetic transminase (GOT-m) were measured after 24 h of reperfusion. The cytotoxic aldehydes malondialdehyde and 4-hydroxy-2-nonenal as indices of lipid peroxidation (LPO), and neutrophil-specific enzyme myeloperoxidase (MPO) as an index of neutrophil infiltration, were measured in the gastrocnemius muscle. RESULTS Contractile functions in the MCI and EPC groups were significantly better than in the control group. In the tibialis anterior muscle, the contractile function was better in the MCI group than in the EPC group. W/D ratios and serum levels of CPK, LDH, GOT, and GOT-m were lower in the sham and MCI groups than in the control group. Levels of LPO and MPO activity were significantly lower in the MCI and EPC groups than in the control group. Histological findings demonstrated that inflammatory tissue reactions rarely occurred in the MCI group. CONCLUSION MCI-186 is effective in preventing ischemia-reperfusion injury in extremities. MCI-186 seems to have promise as a therapeutic agent, because it prevents ischemia-reperfusion injury even in the tibialis anterior muscle, which contains fast-twitch glycolytic fibers, known to be very susceptible to ischemic insult.
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Affiliation(s)
- H Irie
- Department of Clinical Research, National Saishunso Hospital, 2659 Suya, Nishigoushi-machi, Kumamoto 861-1102, Japan
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26
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Shenaq SM, Kim JYS, Armenta AH, Nath RK, Cheng E, Jedrysiak A. The Surgical Treatment of Obstetric Brachial Plexus Palsy. Plast Reconstr Surg 2004; 113:54E-67E. [PMID: 15083009 DOI: 10.1097/01.prs.0000110215.61220.72] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Learning Objectives: After studying this article, the participant should be able to: 1. Understand the natural history of obstetric brachial plexus injury with an emphasis on clinicopathologic features. 2. Develop an awareness of the indications and timing for both nonsurgical and surgical treatment. 3. Acquire knowledge of the current methodologies involved in primary and secondary brachial plexus reconstruction.Obstetric brachial plexus palsy is a potentially devastating form of cervical nerve injury that occurs in 0.38 to 2.6 births per thousand. In this review, we discuss fundamental clinicopathology and delve into the indications and methods of both nonsurgical and surgical strategies. An analysis of the major techniques of reconstruction is placed within the context of historical trends and a contemporaneous survey of the literature. On this basis, and given our own 12-year experience (with 415 surgically treated patients), several general conclusions can be made: (1) Early surgical intervention (3 to 6 months) is essential to optimizing long-term outcome in patients who have not had return of function in critical muscle groups. At Texas Children’s Hospital, we have developed an efficient multidisciplinary approach to primary brachial plexus exploration and reconstruction by integrating the neurosurgical, physical medicine and rehabilitation, neurologic, and plastic surgical services. (2) Secondary residual deformities—most notably the quintessential internal rotation and adduction deformity of the upper extremity—arise from both prolonged conservative management and failed surgical treatment; however, an effective armamentarium of reconstructive options (tendon transfers, muscle releases, neurotizations, and free muscle flap transplantations) has evolved to markedly improve the functional status of these patients. (3) Innovative reconstructive approaches, including nerve grafting, intraplexal and extraplexal neurolysis, and nerve transfers, should be well planned and applied for maximal functional recovery of the extremity. Priorities for the restoration of hand function, elbow flexion, and shoulder abduction should be the goal.
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Affiliation(s)
- Saleh M. Shenaq
- Houston, Texas; From the Division of Plastic and Reconstructive Surgery, Baylor College of Medicine and Texas Children’s Hospital
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27
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Gu Y, Wang H, Zhang L, Zhang G, Zhao X, Chen L. Transfer of brachialis branch of musculocutaneous nerve for finger flexion: Anatomic study and case report. Microsurgery 2004; 24:358-62. [PMID: 15378580 DOI: 10.1002/micr.20053] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Based on an anatomic study, a transfer of the brachialis muscle branch of the musculocutaneous nerve (BMBMCN) to finger flexor functional fascicles of the median nerve was designed. Preliminary results of clinical application of this new procedure are reported. Dissection of 32 cadaver upper limbs revealed that BMBMCN derives from the musculocutaneous nerve at the distal 1/3 upper arm level. Mostly it is of single-branch type, with an average dissectable length of 5.2 cm. At this level, functional fascicles of finger flexors are located at the posterior 1/3 of the median nerve. BMBMCN can be directly coapted to these finger flexion fascicles. In one case of brachial plexus lower trunk injury, this neurotization procedure was done. No impairment of elbow flexion and wrist flexion was found postoperatively. Recovery of finger and thumb flexion was seen 1 year postoperatively. This neurotization is safe and effective for treating lower trunk injuries.
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Affiliation(s)
- Yudong Gu
- Department of Hand Surgery, Hua Shan Hospital, Fudan University, 12 Wulumuqi Zhong Road, Shanghai 200-040, People's Republic of China
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28
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Ikebe K, Kato T, Yamaga M, Tsuchida T, Irie H, Oniki Y, Takagi K. Effect of nitric oxide on the contractile function of rat reperfused skeletal muscle. J Surg Res 2002; 106:82-5. [PMID: 12127812 DOI: 10.1006/jsre.2002.6395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The involvement of nitric oxide (NO) in ischemia-reperfusion injury remains controversial and has been reported to be both beneficial and deleterious. The purpose of this study was to examine the contribution of NO and superoxide to skeletal muscle function using an ischemic revascularized hind limb model in rats. PATIENTS AND MATERIALS Warm ischemia produced by vascular pedicle clamping was sustained for 3 h. The animals were divided into four groups according to the solution administrated: (1) saline, (2) N-methyl-L-arginine acetate (L-NMMA), (3) L-NMMA + N-(N-L-g-glutamyl-S-nitroso-l-cysteinyl)glycine (S-nitrosoglutathione), or (4) superoxide dismutase (SOD). Saline, L-NMMA, or L-NMMA + S-nitrosoglutathione was infused for the first 2 h of reperfusion. The SOD was administered as an intravenous bolus 5 min before the onset of reperfusion. Postischemic blood flow was measured by a Doppler flow meter. Muscle contractile function was determined after 24 h of reperfusion. RESULTS Postischemic blood flow was significantly decreased by the L-NMMA infusion compared with that in the saline-treated group. No significant difference in postischemic blood flow was noted in the saline-, L-NMMA + S-nitrosoglutathione-, and SOD-treated groups. Contractile function of the gastrocnemius muscle in the L-NMMA-and SOD-treated groups, but not in the L-NMMA + S-nitrosoglutathione group, was significantly better than that in the saline-treated group. CONCLUSION Limiting postischemic blood flow and SOD infusion are both beneficial in decreasing the ischemia-reperfusion injury of skeletal muscle. S-Nitrosoglutathione infusion following suppression of endogenous NO production does not reduce ischemia-reperfusion injury.
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Affiliation(s)
- Kenshiro Ikebe
- Department of Orthopedic Surgery, Kumamoto University School of Medicine, Kumamoto, Japan
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29
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Ikebe K, Kato T, Yamaga M, Hirose J, Tsuchida T, Takagi K. Increased ischemia-reperfusion blood flow impairs the skeletal muscle contractile function. J Surg Res 2001; 99:1-6. [PMID: 11421597 DOI: 10.1006/jsre.2001.6134] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The ultimate aim of replantations and transplantations of skeletal muscle is to improve impaired function. The purpose of this study was to examine the contribution of varying durations of ischemia to postischemic blood flow in the skeletal muscle and the contribution of modulation of postischemic blood flow to skeletal muscle function and viability, using an ischemic revascularized hind limb model in rats. MATERIALS AND METHODS Warm ischemia produced by vascular pedicle clamping was sustained for 90 min, 3 h, or 6 h. Postischemic blood flow was measured by a Doppler flowmeter or microsphere technique. In another series of experiments of 3-h ischemia, either saline or N(G)-methyl-l-arginine acetate (l-NMMA) was infused for the first 2 h of reperfusion. Postischemic blood flow was also measured. Muscle contractile function and viability were determined after 24 h of reperfusion. RESULTS Postischemic blood flow was significantly increased during the first 10 min of reperfusion in the 90-minute ischemic group and during the first 2 h in the 3-h ischemic group compared with contralateral control blood flow. No significant increase in postischemic blood flow was noted in the 6-h ischemic group. Postischemic blood flow was significantly decreased by the l-NMMA infusion. Contractile function and viability of the tibialis anterior muscle and contractile function of the gastrocnemius muscle in the l-NMMA group were significantly increased. CONCLUSION Reperfusion blood flow increased time dependently until 3 h of warm ischemia. Hyperemia deteriorated skeletal muscle contractile function, although it was well preserved by l-NMMA infusion to restrict the postischemic hyperemia.
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Affiliation(s)
- K Ikebe
- Department of Orthopedic Surgery, Kumamoto University School of Medicine, Kumamoto, 860-8556, Japan
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30
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Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 2000; 106:1097-1122; quiz 1123-4. [PMID: 11039383 DOI: 10.1097/00006534-200010000-00022] [Citation(s) in RCA: 138] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Posttraumatic brachial plexus palsy is a severe injury primarily affecting young individuals at the prime of their life. The devastating neurological dysfunction inflicted in those patients is usually lifelong and creates significant socioeconomic issues. During the past 30 years, the surgical repair of these injuries has become increasingly feasible. At many centers around the world, leading surgeons have introduced new microsurgical techniques and reported a variety of different philosophies for the reconstruction of the plexus. Microneurolysis, nerve grafting, recruitment of intraplexus and extraplexus donors, and local and free-muscle transfers are used to achieve optimal outcomes. However, there is yet no consensus on the priorities and final goals of reconstruction among the various centers.
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Affiliation(s)
- J K Terzis
- Microsurgery Research Center, Department of Surgery, Eastern Virginia Medical School, Norfolk 23510, USA
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31
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Ihara K, Kido K, Shigetomi M, Kawai S, Doi K, Sakai K. Experience with the pedicled latissimus dorsi flap for finger reconstruction. J Hand Surg Am 2000; 25:668-73. [PMID: 10913207 DOI: 10.1053/jhsu.2000.8645] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The pedicled latissimus dorsi flap was used for the reconstruction of finger function in 12 patients with severely disabled hands. The fascial origin of the muscle was sutured directly to finger flexors in 6 patients, and to extensors in the other 6 patients in the forearm without severing the neurovascular pedicle. Voluntary contraction of the muscle was obtained in all patients. Useful tendon gliding was achieved in 6 patients, thereby providing total active motion of fingers of >100 degrees. In the remaining 6 patients, however, several problems such as stiff finger joints prevented appropriate tendon gliding, resulting in total active motion of <60 degrees. When these problems are overcome, the pedicled latissimus dorsi muscle can yield satisfactory excursion for extrinsic tendons of the fingers. In contrast to free muscle transplantation, early and predictable recovery of function can be obtained using this particular technique without any risk of denervation of the muscle.
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Affiliation(s)
- K Ihara
- Department of Orthopaedic Surgery, Yamaguchi University School of Medicine, Japan
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