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Biomedical subjects

H Millesi

Publications and source records attributed to H Millesi.

At least 19 recordsLinked to original sources
PubMed2006

[Fascial spaces and recurrent surgery for thoracic outlet syndrome].

We studied the passive motion of the brachial plexus in relation to movement of the upper extremity by observation during surgery and by measurements in cadavers. The spaces for these movement are defined. The passive motion is provided by gliding tissue. Pathologic changes of the gliding tissue may contribute to the development of the symptoms of the TOS. It is distinguished between reversible and irreversible changes. A recurrent fibrosis may develop in rare cases which may be best treated by microsurgical neurolysis and envelopment of the brachial plexus by a gliding tissue flap.

Adult↗
PubMed2005

Neurolysis: is it beneficial or harmful?

The term internal neurolysis means removal of fibrotic tissue inside a nerve trunk. Unfortunately the term was used for procedures with complete isolation of fascicles with all consequences like damage of links between the fascicle and impairment of blood supply. The conclusion based on some negative experiences that all surgery within a nerve trunk has to be avoided cannot be accepted. Neurolysis within a nerve trunk, id est within the epineurium, is a step-wise procedure to decompress fascicles from a constricting fibrosis. It stops immediately if this aim is achieved or continues with resection and reconstruction if an irreparable damage is present. It is better to use terms that describe exactly what was done and abandon the ill-defined term "internal neurolysis". Fibrosis of the paraneurium remains outside the epineurium but causes the same consequences as fibrosis of the epineurium.

Connective Tissue↗
PubMed2004

[Surgery of post-traumatic brachial plexus lesions (personal approach in 2003)].

The surgery of traumatic brachial plexus lesions has developed extensively. At present (in the year 2003), five different approaches are utilised: A simple nerve transfer to restore elbow flexion without exploration of the brachial plexus is still recommended. In contrast to this technique, in many centres an extensive exploration of the brachial plexus is performed, to clarify an exact anatomical diagnosis. The treatment depends on the findings and consists of neurolysis, interfascicular nerve grafting, or nerve transfers in case of root avulsions. The surgery of the brachial plexus is followed by an intensive physiotherapy and, when the result of the plexus surgery can be evaluated, by a series of reconstructive procedures to maximise the functional result. The dorsal approach by David Kline is is indicated in special situations. The re-implantation of avulsed roots according to Carlstedt is still in an experimental phase. Doi recommended primary free functional muscle transplantation without exploration of the brachial plexus, which is a waste of muscles which have the potential of regeneration. The free muscle transplantation should be limited to inveterated cases. In the past ten years, the nerve fibre transfer from contralateral C7 according to Gu (1991) has opened a new source for axon sprouts. With this technique very good results can be achieved in elected cases, especially in young patients with a short interval between accident and surgery. The termino-lateral coaptation according to Fausto Viterbo provides axon sprouts from other nerves, without the necessity to sacrifice the function of the donor nerve. Excellent results can be achieved if the donor nerve is a small pure motor nerve, and the recipient nerve as well, in order to avoid a dilution of axon sprouts. Knowledge of the different fascial systems around the brachial plexus helps to facilitate the exploration. This is especially important in the area of the cuppula pleurae (membrana suprapleuralis Sibson). A detailed description of this system is provided. Pathology of the root-nerve complex is more complicated and cannot be reduced to the simple alternative "either root avulsion or rupture". Inspite of improvement of diagnostic means, cases are seen frequently in which--under the diagnosis "complete root avulsion"--non-avulsed roots have not been recognized and have not been used as donors for axons. MR-imaging has a failure rate and cannot be relied upon for surgical decision making. If the continuity of a root is proven, it is not sure that this root is really conducting and that there is a sufficient potential for regeneration. The only way to gain knowledge about the conductivity of roots in continuity is the "Central stimulation according to Turkof". This technique should be improved and one should get a quantitative answer. A surgical exploration of the brachial plexus, even if root avulsions are suspected, is mandatory. The most important point, as far as the brachial plexus lesion is concerned, is a combined approach: The brachial plexus lesion should be attacked directly, and as much reconstruction should be performed at the level of the brachial plexus as is possible. In elected cases, a C7 transfer might be indicated in a second stage. Surgery on the brachial plexus is followed by a period of intensive physiotherapy. When the result of the surgery on the brachial plexus can be evaluated, all possibilities of reconstructive surgery have to be applied to maximise the result.

Adult↗
PubMed2000

Techniques for nerve grafting.

The nerve graft can be completed using many different techniques. This article elaborates the general principles and many details that can be approached in different ways when dealing with nerve grafting. A review of the reasons for the poor performance of early nerve grafts, as well as the origins of nerve grafts, is included. This article discusses the technical aspects of nerve grafting including free nerve grafting and timing and exposure.

Arm↗
PubMed1999

[Compression syndromes of the axillary nerve and the suprascapular nerve].

We report on seven patients with altogether four paralyses of the axillary and six paralyses of the suprascapular nerve without a singular trauma. In one patient, the paralysis of the axillary nerve developed spontaneously over night after a period of habitual dislocations of the shoulder joint. Another patient developed a paralysis of the suprascapular nerve after prolonged wearing of a rucksack. Three of the remaining five patients developed both an axillary and suprascapular paresis without any preceeding trauma or irritation. In two further patients, an isolated suprascapular paralysis developed without trauma. An analysis of the intraoperative findings in these five patients shows in all cases adhesions of the nerve with the surrounding tissues at the site of the suprascapular notch respectively the quadrilateral space. In all three cases of axillary nerve paralysis there was in addition a narrow quadrilateral space. However only in three of five suprascapular nerve lesions there was a narrow suprascapular notch. In the two remaining cases adhesions alone had caused the paralysis and produced a serpentine deformity of the nerve. It is concluded that inflammatory processes cause the paralysis and the adhesions. Compression in the narrow space and fibrous changes are responsible for maintaining the paralysis after the inflammation has subsided. Macroscopically unchanged nerves underwent external neurolysis. With fibrous changes an epineuriotomy and with more pronounced changes an epineuriectomy were performed. The results are discussed.

Adult↗
PubMed1998

[Late lesion of the brachial plexus after clavicular fracture].

Neurological complications in clavicle fractures are rare. As a primary lesion, it is caused by the trauma itself. More often however, the neurological symptoms develop later by large callus formation that encroach on the costoclavicular space. A case report is presented of delayed injury to the brachial plexus due to clavicular fracture with non-union and callus formation.

Adult↗
PubMed1998

[Results of restoration of continuity in peripheral nerves in childhood and adolescence].

According to several studies, results after reconstructive procedures in children are generally superior compared to those in adults. In the present retrospective study, 20 patients after reconstruction of one or more major nerves in the upper limb (median, ulnar, and radial nerves) were examined. At the time of operation, the patients' age was 8.9 years on the average, the follow-up time ranged between 29 and 173 months. In six cases the nerve lesion had been treated by direct nerve coaptation, in 14 patients a primary or secondary nerve grafting procedure had been applied. The results were classified according to Millesi's examination system, which takes several factors such as mobility, sensibility, skill, and force of the hand into account. Besides two patients, one after reconstruction of the median and ulnar nerves by grafts with significant destruction of the muscles in the lower arm, and the second one after primary coaptation of the median and ulnar nerves in the elbow region, all patients showed a hand function of more than 70% according to Millesi's scoring system. In patients older than ten years at the time of the reconstructive procedure, results were slightly worse than in younger individuals. Children up to ten years of age were nearly always able to move their hand and fingers normally. The results after nerve grafting were sometimes even superior to those after primary neurorrhaphy. Therefore, the present study supports the findings of previous authors describing the excellent regenerative potential of the growing peripheral nervous system. Furthermore, Millesi's scoring system better revealed some subtle differences in hand function when compared to other classifications.

Adolescent↗
PubMed1998

[Actinic brachial plexus lesion].

Radiation-induced brachial plexus lesions are progressive and irreversible complications. Until now, there is no way to successful prevention and treatment of this problem. In our series, relief of pain could be achieved by neurolysis in some cases, but there was no recovery of sensory and motor function. In order to improve the vascularity and nerve tissue regeneration, we performed muscle or gliding tissue flaps after neurolysis in our department. Since 1975, 25 patients who developed radiation-induced plexopathy were treated in our department. We followed 18 patients to evaluate the benefits of our surgical intervention. None of the patients had improvement of their sensory or motor impairment. Relief of severe pain was achieved in 83% either by neurolysis only with or without muscle or gliding tissue flap. In some cases, paresis worsened postoperatively. We also observed a return of severe pain after the operation.

Adult↗
PubMed1998

[Analysis of hand function with the Millesi examination scale in patients with pollicisation after aplasia or hypoplasia of the thumb].

Pollicisation of a single long finger is the method of choice to treat congenital thumb aplasia or thumb hypoplasia. Using Millesi's scale for the functional analysis of the hand, we examined six patients treated in the years 1983 to 1994 in our service. Average age at the time of surgery was 2.4 years and the follow-up time was seven years on average. Of the six patients, four suffered from additional malformations of the ipsilateral arm. These anomalies required early surgical treatment and therefore delayed the pollicisation procedure. The results of the anatomical part of the examination ranged between 39 and 94% of the achievable value. The final results including sensibility, strength, and skills reached 11 to 50%. Development of skills and muscle strength in the operated hand was dependent on the follow-up time. Millesi's scale could be applied successfully in this special group of children with congenital malformation of hands.

Child↗
PubMed1997

Intraoperative electroneurodiagnostics (transcranial electrical motor evoked potentials) to evaluate the functional status of anterior spinal roots and spinal nerves during brachial plexus surgery.

Intradural spinal root lesions cannot be recognized by dissecting the brachial plexus and lead to ineffective surgery if they remain undetected. Therefore, patients need to undergo a diagnostic procedure to assess the intradural status of the spinal roots. Although motor recovery is the main goal of brachial plexus surgery, the techniques currently applied do not permit adequate evaluation of the anterior root. In search of an alternative, we performed intraoperative motor evoked potentials. Ninety spinal nerves in 19 patients suffering from brachial plexus lesions were dissected. Twenty-seven spinal nerves were avulsed; 8 nerves were disrupted and 17 were completely scarred, resulting in 25 stumps. Thirty-eight nerves appeared to be undamaged. On central stimulation, nerve compound action potentials were recorded from the exposed spinal nerves. Nerve compound action potentials could only be recorded from 21 stumps and from 32 apparently undamaged nerves. No recordings were obtained from 4 stumps and 7 spinal nerves in continuity. According to these findings, it is highly probable that surgery would have been insufficient in 10 spinal nerves if intraoperative motor evoked potentials had not been performed. We conclude that (1) intraoperative motor evoked potentials are an effective means for investigating the functional status of anterior motor roots and motor fibers in exposed spinal nerves, and (2) the use of motor evoked potentials should be considered during brachial plexus surgery to improve interventions.

Action Potentials↗
PubMed1996

Split nerve grafting.

Twenty-five patients with severe brachial plexus lesions (having a rather poor prognosis in general), were subjected to a variety of split nerve graft procedures, with 22 achieving useful functional recovery. Thirty-eight nerves were reconstructed, with 32 of them achieving useful recovery. Results in these patients were no better nor worse than those obtained with other types of nerve grafts (e.g., free cutaneous nerve grafts, vascularized nerve grafts, etc.). The technique of splitting the nerve for the use of split fascicle groups as free nerve grafts is nevertheless recommended as an alternative to the application of the ulnar nerve as a vascularized nerve graft. The plexiform arrangement of the fascicles within the ulnar nerve apparently does not preclude the possibility of harvesting sufficiently long nerve grafts.

Adolescent↗
PubMed1996

[Analysis of change in finger function after flexor tenolysis].

39 fingers in 31 patients were examined on the average of 117,6 months after flexor tenolysis of the finger. Results were classified according to Millesi's scheme and compared to the preoperative situation. For control, the criteria according to Buck-Gramcko were applied as well. In 23 fingers tenolysis resulted in an improved function, 13 cases remained unchanged and three cases were seen worse than before tenolysis. The number of improved fingers, the gradual improvement and the final result depended upon the affected finger and the primary operation which proceeded tenolysis. Best results were obtained in the thumb and after primary tendon repair. The results which were classified according to Millesi's scheme showed a highly significant correlation to those according to Buck-Gramcko's classification.

Adult↗
PubMed1995

Biomechanical properties of normal tendons, normal palmar aponeuroses, and tissues from patients with Dupuytren's disease subjected to elastase and chondroitinase treatment.

Normal tendons, normal palmar aponeuroses and palmar aponeuroses from patients with Dupuytren's disease were subjected to elastase or chondroitinase treatment. Young's modulus was derived from the linear portion of stress-strain graph. It showed the lowest value for the apparently normal palmar aponeuroses and the highest value for tendon samples. Elastase treatment caused an increase of extensibility and a reduction of Young's modulus of normal palmar aponeuroses and tendons, but not of contracture bands. In normal tendons, normal palmar aponeuroses and apparently normal palmar aponeuroses residual strain and hysteresis loop increased significantly as a linear function of the amount of digested elastin. In contrast these biomechanical parameters were not affected significantly in contracture bands. In normal and apparently normal areas incubation with chondroitinase ABC resulted in a significant increase of residual strain and, as opposed to elastase, a decrease of normalized hysteresis loop. In contracture bands, however, these biomechanical parameters remained unchanged. RELEVANCE: The increasing evidence of a correlation between morphological changes of palmar elastin and ground substance with the progress of Dupuytren's disease emphasizes the need to determine the relative importance of these connective tissue components for the pathogenesis of Dupuytren's disease.

Journal Article↗
PubMed1995

Motor evoked potential as a reliable method to verify the conductivity of anterior spinal roots in brachial plexus surgery: an experimental study on goats.

The goal of this experimental study was to confirm the reliability of motor evoked potential (MEP) in testing the function of anterior motor roots in brachial plexus surgery. On central stimulation, nerve compound action potentials (NCAPs) are registered from the exposed spinal nerves. If NCAPs can be recorded, the anterior root is considered to be intact. Two factors might cause positive recordings even in the presence of an avulsed anterior motor root: volume conduction, and impulse transmission through an intact posterior root. In five Nubian goats, spinal nerves C6, C7, and their corresponding spinal roots were dissected. On central stimulation, NCAPs were repeatedly recorded from the surface of all ten spinal nerves. Then, the anterior motor roots were transsected and central stimulation repeated. NCAPs disappeared irreversibly in all ten tested spinal nerves. The experiment showed that, on central stimulation, NCAPs cannot be recorded from spinal nerves unless the anterior root is intact.

Animals↗
PubMed1995

Biomechanical properties of normal tendons, normal palmar aponeuroses and palmar aponeuroses from patients with Dupuytren's disease subjected to elastase and chondroitinase treatment.

Normal tendons, normal palmar aponeuroses and specimens from patients with Dupuytren's disease, namely apparently normal palmar aponeuroses and contracture bands were subjected to elastase and chondroitinase ABC digestion. Maximum Young's modulus, normalized hysteresis loop and residual elongation were determined before and after enzyme treatment. In normal tendons, normal and apparently normal palmar aponeuroses both normalized hysteresis loop and residual elongation increased significantly after elastase treatment, whereas the stiffness decreased. Normalized hysteresis loop and residual elongation display changes corresponding to the amount of digested elastin. The increased viscosity of untreated contracture bands containing less elastin, as compared to normal palmar aponeurosis, was not affected by elastase. Obviously, the elastic fibers in normal shape and distribution are responsible for maintaining an elastic status with a low viscous stress component. With the exception of contracture bands chondroitinase ABC caused a minor increase of residual elongation and as opposed to elastase a decrease of normalized hysteresis loop indicating an increased mobility of the tissue fibers.

Animals↗
PubMed1995

Intraoperative electroneurodiagnostics to detect a second granuloma in the cubital area of median nerves affected by leprosy: a new approach to prevent incomplete surgery.

A recent work reports on the necessity to localize the most proximal site of leprous ulnar neuritis with intraoperative electroneurodiagnostics. In the present study we wanted to verify the applicability of this method on leprous median nerves. In six patients, seven median nerves were exposed at the wrist, all showing a typical leprous granuloma there. Spinal roots C5 to Th1 were then stimulated intraoperatively, evoking efferent mixed nerve compound action potentials (NCAPs) which were registered from the nerve's surface. No recordings could be obtained on the granuloma in all patients, neither distally nor shortly proximal from it, nor even further central at the forearm's proximal third where the median nerve exits the cubital area. Prior to dissecting the nerves in this precarious region, they were exposed at the arm's distal third, looking inconspicuous in all cases. Recordings could finally be obtained there, and subsequent exposure further proximal showed no increase in amplitude of the NCAPs, but there was a sharp decrease distally. In all cases, subsequent dissection of the cubital area revealed a second leprous granuloma extending variably from the distal third of the arm to the two heads of the pronator teres muscle, requiring microsurgical release. Intraoperative spinal root stimulation is an effective method to detect a second leprous granuloma and to avoid incomplete surgery in median nerves affected by leprosy.

Action Potentials↗
PubMed1995

Mechanical properties of peripheral nerves.

Peripheral nerve trunks are viscoelastic tissues with unique mechanical characteristics. Tensile strength, which includes elastic limit and mechanical failure, concerns surgeons. This study shows that measurements of the load necessary to achieve certain elongations on specimens outside the body do not correspond with in situ measurements. The necessary load is influenced by the presence or absence of branches and by the amount of fibrosis. Because of transverse contraction, elongation beyond a certain limit substantially decreases intrafascicular volume, leading to increased intrafascicular pressure. Stress relaxation is effective only if the nerve repair site is maintained under constant tension. Its beneficial effect disappears after 10 minutes if the repaired nerve is returned to a relaxed state. Therefore, tension at the repair site should be minimized.

Biomechanical Phenomena↗