Strategy changes of neurotization before and after 2000

From 1986 to 2000, over 1000 adult patients with brachial plexus injury were operated on by the author. From 2000 to present, the author has performed an average of 66.7 brachial plexus operations every year. Seventy-five percent of patients sustained preganglionic root injuries that required a neurotization procedure either for nerve reconstruction or for functioning free muscle transfers. Strategy changes occurred before and after 2000 following retrospective study reviews, accumulation of...

Upper limb bone defectindications for vascularized bone transfer

In general, most authors suggest that the strongest indications for the use of vascularized bone graft include situations that are prone to failure or complications with technically less demanding techniques such as nonvascularized bone autografts or allografts. These situations include massive defects and or an unfavorable surrounding soft tissue milieu related to prior failure of conventional bone grafting failure, infection, radiation, or other causes of extensive scarring. 1. Recipient site...

Functioning free muscle transplantation

Functioning free muscle transplantation (FFMT) describes the transfer of a muscle using microvascular anastomoses for revascularization and subsequent neurorraphy of the muscle's motor nerve to a recipient motor nerve for reinnervation. The use of FFMT in brachial plexus reconstruction is another example of the application of neurotization and it has been shown to be effective and has become increasingly popular. The gracilis myocutaneous FFMT is the best choice for the donor muscle in brachial...

Reconstruction of multiple finger amputations

Toe Thumb Transplant Photos

When presented with the even more devastating amputations that involve several fingers, sometimes bilaterally, the reconstructive plan becomes more complicated. Replantations must be attempted whenever indicated and possible 28,29 . For nonreplantable amputations, toe transplantation remains the most useful reconstructive option 28,29 . Initial evaluation must entail a detailed and thoughtful discussion about the patient's special skills, occupation, handedness, and hobbies. It should be...

References

Surgical treatment of avulsion type injuries of the brachial plexus. In Brunelli G, editor. Textbook of microsurgery. Milan (Italy) Masson 1988. p. 781-7. 2 Millesi H. Update on the treatment of adult brachial plexus injuries. In Gilbert A, editor. Brachial plexus injuries. Martin Dunitz Ltd 2001. p. 77-90. 3 Terzis JK, Papakonstantinou KC. The surgical treatment of brachial plexus injuries in adults. Plast Reconstr Surg 2000 106(5) 1097-122. 4 Alnot JY. Traumatic paralysis of...

Operative technique of muscle transplantation to the arm for biceps function

Loss of elbow flexion can be a devastating disability. Fortunately, the biceps muscle and the brachialis muscle are capable of performing this function. Thus, the direct loss of one or the other does not eliminate this function. The loss of both and the weakening of both can have significant functional consequences, however. In brachial plexus reconstruction, significant priority is given to elbow flexion. At their center, the authors have not had experience with this but have only performed...

Selection of free flaps

The selection of a free flap is dependent on the following assessment of the recipient site size and depth mechanism of injury exposed structures structures needing reconstruction contamination the color and texture of the tissues surrounding the defect and the need to restore sensation 8,17 . It is important to realize that following radical de-bridement the wound is often much larger and deeper than anticipated, and the microvascular anastomoses must be placed well out of the zone of injury....

Neurotization

Triple Nerve Transfer

Neurotization is a surgical procedure that intentionally divides a physiologically intact nerve with little morbidity and transfers it to a distal more important but irreparably denervated nerve. The procedure is best done within a golden time period, which is defined as within 5 months of injury 8,9 , to reactivate a paralyzed muscle or muscle groups early (4 to 6 months postoperatively), effectively, and successfully (M4 muscle strength). Neurotization can be broadly classified into four...

Gracilis muscle dissection and muscle insertion

Gracilis Myocutaneous Flap

The gracilis muscle or myocutaneous FFMT is the best choice of donor muscle for elbow or hand reconstruction in BPI reconstruction. The requirement for a myocutaneous flap is more common than muscle alone to allow monitoring of the flap's viability. The gracilis muscle is a long strap muscle with a long distal tendon, vascular-ized by a long dominant neurovascular pedicle. A single motor nerve, the anterior branch of the obturator nerve, can be dissected and traced upward to the obturator...

Microsurgical technique

Arthroscopic Brachial Plexus Neurolysis

Millesi 1,2 pioneered the techniques of microsurgical repair of peripheral nerves. Microsurgical techniques are absolutely required for a technically good nerve repair. The operating microscope should be used whenever possible, however surgical loupes (at least x3.5 magnification) are adequate in areas where placement of the microscope is difficult. In challenging locations, the operating microscope can be introduced after the repair to confirm a good-quality repair. The operating microscope...

The Role of Microsurgery in Nerve Repair and Nerve Grafting

Linda Dvali, MD, SM, FRCS(C)a, Susan Mackinnon, MD, FRCS(C), FACSb * Division of Plastic Surgery, University of Toronto, 2E-400, 399 Bathurst Street, Toronto, Canada M5T 2S8 bDivision of Plastic and Reconstructive Surgery, Washington University School of Medicine, 660 South Euclid, Box 8238, Suite 5401, St. Louis, MO 63110, USA The capacity of peripheral nerves to regenerate their axons and reinnervate distal targets after injury has been recognized for more than a century. Despite this...

Volkmanns ischemic contracture

Volkmann's ischemic contracture was first described by Volkmann in 1881 17 . The contracture follows a supracondylar fracture in which there has been circulatory embarrassment. This has led to a compartment syndrome that has progressed to the classic picture of Volkmann's ische-mic contracture. The end result is a pronated forearm, a flexed wrist, an adducted thumb, and the metacarpal phalangeal joints extended. The interphalangeal joints of the fingers and thumb are in a flexed position (Fig....

Incomplete brachial plexus palsy in the adultupper lesions C5 C6 C7

There is little controversy regarding the relative roles of conventional techniques versus microneurosurgical reconstruction for incomplete brachial plexus palsies that involve primarily the upper elements of the plexus (ie, C5-C6 or C5-C7 palsies). The patients retain useful hand function but are unable to position this functional hand to perform necessary tasks. The patients' issues relate to control of the shoulder and elbow, and less frequently, the wrist. The relative roles of conventional...