Biomedical subjects
Publications and source records attributed to G Brunelli.
The case is reported of a young girl who was bitten on the hand by a viper and developed compartment syndrome of the intrinsic muscles more than 24 h later. Multiple dorsal and volar fasciotomies resolved the acute episode with complete restitutio ad integrum. The clinical case is discussed in detail and the literature on these rare complications of snake bites in European countries reviewed.
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The authors discuss free microvascular bone transfers in general, and propose a new classification for idiopathic femoral head necrosis. They then present a technique they have been using for 11 years, with the goals of providing both mechanical support and an improved blood supply to the femoral head. This technique involves clearing the necrotic area of the femoral head, filling the area with cancellous bone taken from the greater and lesser trochanters, and transferring a fibular microvascular graft. The approach is transtrochanteric and spares the capsule. Vascular anastomosis is done with the lateral branches of the deep femoral artery, sparing the anterior circumflex artery which is important to the blood supply of the femoral head. Forty-five cases have been surgically managed over 11 years. Eighteen cases with follow-up longer than five years were analyzed, providing an 84 percent successful outcome with both very good and good results.
There is a lack of agreement regarding the potential for peripheral nerve cells with short axons to regenerate and innervate the terminal end organs of nerve cells with long axons. We designed a study to evaluate experimentally the possibility of neurons to reconstitute much longer axonal segments. Twenty Wistar rats were used. The brachial plexus was isolated and the radial nerve transected immediately after its origin. The proximal end of the axillary nerve (previously cut) then was coapted tot he distal stump of the radial nerve. In 10 other rats, the cut radial nerve was simply recoapted to itself without involvement of the axillary nerve; these animals served as controls. Finally, in 10 rats, nerves were cut without repair to evaluate the degenerative changes. After 90 days, the distal part of the radial nerve was examined by light microscopy, calculating the number and area of regenerated axons. We also checked the motor end-plates of reinnervated muscles. In the nerve-transferred group, good axonal regeneration with good reinnervation of the muscles was seen. In this way, we have experimentally demonstrated a plasticity of regeneration in peripheral nerves. This suggests that the surgeon may use nerves connected to proximal muscles to neurotize avulsed nerves of distal muscles.
The authors review the latest theories of peripheral nerve regeneration and repair. They present their research on nerve regeneration including the alterations in the mother cell body, and in the distal part of the axon, and the time required to reach the best production of amino acids for cytoskeleton reconstruction. Other research of particular interest which is presented regards the chemotactic arrangement of motor and sensory axons inside a vein. This research has shown that the axons are able to find their way to the appropriate (sensory or motor) distal endoneural tubes. Adoption phenomena are also presented. The discussion of surgery includes the type (suture, glueing, grafts, tubulization) and the time of surgical repair. Timing and repair strategies are related to the site of the lesion (which can require that a greater or smaller amount of cytoskeleton be reconstructed), the type of the injury, the state of surrounding tissues, the age of the patients, injuries to muscles, tendons, bones, vessels and skin. A scheme of strategy is proposed.
The authors present a technique of direct muscular neurotization consisting of re-innervation by direct implantation of a nerve into one or several muscles in cases of avulsion of the nerve supplying the muscle or traumatic or surgical avulsion of the neural part of the muscle. The biological basis for this operation is that a denervated muscle can accept a new innervation by a foreign nerve even in an aneural zone because its sensitivity to acetylcholine is present throughout the muscle, while, in a normally innervated muscle, sensitivity to acetylcholine is confined to the motor endplates. The results of 47 cases are presented: 42 of them obtained good or very good results.
Arthrodesis of the wrist in cases of paralysis of the upper limb, although rejected by certain authors, is a valid operation provided it is confined to certain indications such as paralyses requiring minimal muscle transfers. Arthrodesis of the wrist is particularly useful in the sequelae of brachial plexus lesions with dissociated paralysis and in total paralysis of the radial nerve with hand drop and preservation of the wrist flexors. Numerous techniques of arthrodesis have been proposed. Over the last 27 years, the authors use a technique with a direct dorsal incision. The first row of carpal bones and the radius are roughened with chisel. A cortico-cancellus graft is then raised from the dorsal surface of the radius, leaving a distal cortical bridge. The graft is slid under this bridge, placed onto the roughened surface of the carpus and pushed under the operculum raised at the base of the 2nd and 3rd metacarpals. The arthrodesis is fixed with two Kirschner pins and a plaster for 3 months. We have used this technique in 31 patients with nerve paralyses since 1971 and have obtained complete consolidation with total patient satisfaction in all but one case.
The interaction of threshold doses of bradykinin (BK) and substance P (SP) with acetylcholine (ACh)-induced bronchospasm was investigated in anaesthetized guinea-pigs. The two peptides potentiated the ACh-induced bronchospasm, an effect which did not seem to depend on prostaglandin release. On the other hand, vagotomy abolished the capacity of BK and SP to potentiate the ACh-induced bronchospasm. The present data suggest a possible involvement of BK and SP in the genesis of airway hyperreactivity.
A new technique of trapezio-metacarpal stabilisation is described which uses the abductor pollicis longus tendon passed through the bases of the first and second metacarpals to fasten the base of the thumb. A biomechanical rationale is presented, as well as the surgical technique and 12 results at follow-up one to six years later.
The present evaluations of hand invalidity are based on parameters that can give correct assessment for amputations or for single stiffness, but these parameters are not able to evaluate the majority of lesions. A nerve lesion does not repair at 100% or at 0%; all degrees are possible. The same is true for vascular, tendon and muscular lesions. We studied a new global evaluation on a large number of patients and we compared it with the tables in use today. The assessed parameters are: the active and passive movement, ability of the hand, strength, duration of the effort or of the fatigue, trophism, sensibility, pain, aesthetics.
The occurrence of beta-adrenoceptor desensitisation in clinical experience, after long term therapy with specific beta 2-agonists, is still an open question, even if this phenomenon is easily observed in different experimental models. Since the majority of these experiments have been performed in normal animals, we investigated the possible occurrence of beta-adrenoceptor desensitisation in the ovalbumin actively sensitised guinea-pig model of experimental asthma. The isoproterenol concentration-response curves performed in pilocarpine contracted guinea-pig trachea in vitro were shifted to the right by the beta-adrenoceptor desensitisation procedure, which was achieved by the in vitro administration of isoproterenol (10(-5) M x 2 times x 20 min each) both in normal and ovalbumin sensitised tissues. The same desensitisation procedure markedly affected epinephrine-relaxing capacity in both normal and ovalbumin actively sensitised guinea-pig tracheae. However, the ovalbumin sensitised tissue seemed to be more sensitive than normal to the specific beta 2-agonist procaterol; in parallel the beta 2-mediated relaxation was more impaired by isoproterenol-induced beta-adrenoceptor down regulation in ovalbumin sensitised trachea when compared to normal. Similar results have been obtained using salbutamol as the beta 2-adrenoceptor desensitising agent. The changes in beta-adrenoceptor reactivity between normal and ovalbumin sensitised guinea-pig tracheae seemed to depend on the active sensitisation process. No difference in the degree of beta-adrenoceptor down regulation was observed in passively ovalbumin sensitised guinea-pig trachea as compared to normal. These data suggest that, in this model of experimental asthma, beta-adrenoceptor reactivity is in some way modified and that this phenomenon might contribute to the genesis of asthma.
Pulmonary hyperreactivity is a common feature in asthma. In the present study we investigated the possible role of different mediators in the genesis of this phenomenon. In particular the ability of prostaglandin D2 (PGD2), substance P (SP) and bradykinin (BK) to potentiate acetylcholine (ACh)-induced bronchospasm was assessed in anaesthetized and mechanically ventilated guinea-pigs. Threshold doses of PGD2, SP and BK significantly enhanced ACh-induced bronchospasm in normal guinea-pigs, even if a different trend in the onset and duration of the phenomenon was observed. Ovalbumin (OA) active sensitization modified the ability of the three compounds tested to positively interact with ACh. Beta-adrenoceptor blockade due to propranolol treatment increased the positive interaction between the three compounds and ACh. The role of PGD2, SP and BK in the genesis of pulmonary hyperreactivity is proposed and the relevance of mediator-mediator interaction during adrenergic imbalance is discussed.
The Authors report their experience with 222 esophagoenteric anastomoses, performed in 211 cases for malignant neoplasms (middle and lower third) of the esophagus or stomach. Particularly, they have performed 4 Sujura operations, 31 esophagogastric, 4 esophagocolic, 183 esophagojejunal anastomoses utilizing SPTU, ILS and EEA circular stapler. GIA was used in the preparation of the stomach before esophagogastroplasty. Mortality rate of the manual period (1970-1980: 114 cases operated) was 14.5% versus 2.2% of the stapling period (1981-1987: 222 cases operated). From the technical point of view reasons of the superiority of stapled technique are discussed and summarized as follows: 1) space not favourable for handsewn anastomoses; 2) stapled technique allows the surgeon to save anastomoses vascularization; 3) the stapler performs the suture simultaneously so to reduce tensile strength on the anastomoses and the fragile esophageal wall especially; 4) stapled agraphes are fixed in three points vs. the two points of the handsewn stitches.
The study was performed on a group of 91 children with their first febrile convulsion whose parents were then instructed in the use of rectal diazepam in the event of a further seizure. later, the families were periodically recalled for interviews. The aim was to study the acceptance and cooperation of the families, the psychological attitude and the relation between the findings and parents' educational level. At the end of the follow-up, 80% of the 91 families showed good cooperation and psychological benefits. There was no relationship between the findings at the end of the follow-up and families' educational level. Even in the presence of a favorable psychological attitude, recurrences of febrile convulsions were still a frightening experience for many parents.
A follow-up of 78 patients with acromio-clavicular dislocation who have been operated on since 1956 is reported. The tendon of the short head of the biceps is transferred to the clavicle to obtain, and maintain, reduction. The site of transfer in the last 51 cases has been to a point on the clavicle immediately above the coracoid process. The acromio-clavicular joint is only opened when an obstruction to reduction is present. The functional results in this group of patients are very good.
Aneurysms in the hand are infrequent and aneurysms of the proper digital arteries are particularly rare, only 11 cases having been reported in the literature. The authors describe the case of a patient operated on for two traumatic false aneurysms of the ulnar digital arteries of the middle and ring fingers. Arterial aneurysms should be carefully evaluated to exclude other lesions such as cysts, abscesses, neuromas. The choice between ligation and resection or reconstruction of the vessel should be based on pre-operative and intra-operative evaluation of circulation.
Inflammatory process of the airways has been claimed to be relevant to the development of bronchial hyperreactivity in different experimental models. We investigated the consequences of pleural inflammation induced in the guinea-pigs by croton oil injection into the pleural space. Croton oil injection was followed by the development of an inflammatory reaction localized to the pleura as shown by recovery of inflammatory exudate from the pleural cavity of treated animals. An increased number of white cells was observed in the pleural fluid of treated animals as compared to control. Moreover, the croton oil induced inflammation was characterized by development of pulmonary hyperreactivity which involved both airway and vascular smooth muscles. We also studied this phenomenon in an animal model of asthma, such as the actively sensitized guinea-pigs. Polymorphonuclear leukocyte and particularly eosinophil recruitment was increased in this experimental condition and a different trend in the development of the hyperreactive phenomenon was observed. Our data support the relationship between inflammatory process within the pleural space and increased reactivity of pulmonary tissues. The possible involvement of different classes of white cells in this phenomenon has also been discussed.