The Journal of hand surgery
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The use of conjoint flaps based on the dorsalis pedis artery enabled a transfer of 3 free flaps-dorsalis pedis flap, fillet flap of the second toe, and trimmed large toe-to reconstruct a severely traumatized hand in a 12-year-old girl. High-voltage electrical burn injury had caused a large wound over the volar wrist and exposed the flexor tendons and median/ulnar nerves. In addition, she suffered a partial loss of the thumb and had an open wound at the base of the index finger. The application of the conjoint flaps restored hand function in a one-stage procedure.
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The effect of the A3 pulley and adjacent sheath integrity on tendon function at the proximal interphalangeal (PIP) joint was investigated in 21 fingers in 7 fresh-frozen cadaver hands. Excursions of the flexor digitorum profundus (FDP) tendons were measured when the tendons were pulled to produce PIP joint flexion of 110 degrees from a resting position of 0 degrees. Excursions of the FDP tendons in 10 fingers were tested within the intact sheath and after incision of the A3 pulley, of the A3 pulley with its proximal sheath up to the distal border of the A2 pulley, and of the sheath between the A2 and A4 pulleys. ⋯ Tendon bowstringing was 0.3 mm after incision of the A3 pulley, 0.6 mm after incision of the A3 pulley with its distal sheath, 0.8 mm after incision of the pulley with its proximal sheath, 1.4 mm after incision of the sheath from the A3 to A4 pulleys, and 1.6 mm after incision of the sheath between the A2 and A4 pulleys. The results suggest that the sheath adjacent to the A3 pulley plays an important role in restraining tendon bowstringing at the PIP joint, whereas the A3 pulley alone is of little importance. This study elucidates the role of individual parts of the sheath around the PIP joint in maintaining tendon function and may guide decisions regarding the area and length of the sheath feasible for surgical release or requiring repair in the treatment of tendon lacerations.
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Intraoperative measurement of choline acetyltransferase (CAT) activity was used for evaluation of the functional status of donor nerves during functioning free muscle transfer (FFMT). Twelve patients underwent the procedure. Seven patients had a brachial plexus injury, 3 Volkmann's contracture, 1 chronic peroneal nerve injury, and 1 forearm extensor muscle loss after wide resection of soft tissue sarcoma. ⋯ Fascicles with greater than 2,000 cpm CAT activity were considered to reliable and used as donor motor nerves. All muscles had reinnervation by 3.2 months (range, 2-5 months) and obtained useful recovery. Intraoperative measurement of CAT activity can provide direct and quantitative information about the functional status of donor nerves during FFMT.
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Twenty-three toe-to-hand transfers performed in 21 children were monitored after surgery using differential pulse oximetry for 4 to 12 days. Pulse rate recorded by the pulse oximetry monitored the patency of the arterial anastomosis, whereas oxygen saturation (SaO(2)) corresponded to the patency of the venous anastomosis; these were both compared with the systemic pulse rate and oxygen saturation recorded by a second control pulse oximeter probe attached to a contralateral finger or toe. ⋯ If the oxygen saturation of the toe transfer decreases below the oxygen saturation measured by the control pulse oximeter and this differential is sustained over a period of time, thrombosis of the venous anastomosis should be suspected. Differential pulse oximetry appears to be superior to temperature monitoring and percutaneous and laser Doppler monitoring and provides the most simple and continuous technique of noninvasive postoperative monitoring of toe-to-hand transfers in children requiring reconstruction of traumatic or congenital deformities.
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The aim of this study was to investigate the potential for stimulating axonal regeneration in the context of end-to-side coaptation using a combination of nerve growth factor and ciliary neurotrophic factor in the rat sciatic nerve model. Four experimental groups (n = 8) were used: end-to-side coaptation only, end-to-side coaptation plus growth factor injection, primary repair, and nontransferred gap control. Twenty weeks after surgery histologic analysis showed that the ratio of axon density was significantly increased for the growth factor injection group. ⋯ Another conclusion is that contamination from the proximal peroneal stump may explain the regeneration observed in the end-to-side model. Further study using retrograde labeling is needed to establish the origin of the regenerating axons. Finally, evidence suggests that regenerating axons can use the epineurium of an intact nerve to bridge a gap in continuity.