Harvesting of the sural nerve using a stripper.
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Humans↗
Biomedical subjects
Kartik G Krishnan
Publications and source records attributed to Kartik G Krishnan.
The clinico-anatomic explanation for tibial intraneural ganglion cysts arising from the superior tibiofibular joint.
OBJECTIVE: To demonstrate that tibial intraneural ganglia in the popliteal fossa are derived from the posterior portion of the superior tibiofibular joint, in a mechanism similar to that of peroneal intraneural ganglia, which have recently been shown to arise from the anterior portion of the same joint. DESIGN: Retrospective clinical study and prospective anatomic study. MATERIALS: The clinical records and MRI findings of three patients with tibial intraneural ganglion cysts were analyzed and compared with those of one patient with a tibial extraneural ganglion cyst and one volunteer. Seven cadaveric limbs were dissected to define the articular anatomy of the posterior aspect of the superior tibiofibular joint. RESULTS: The condition of the three patients with intraneural ganglia recurred because their joint connections were not identified initially. In two patients there was no cyst recurrence when the joint connection was treated at revision surgery; the third patient did not wish to undergo additional surgery. The one patient with an extraneural ganglion had the joint connection identified at initial assessment and had successful surgery addressing the cyst and the joint connection. Retrospective evaluation of the tibial intraneural ganglion cysts revealed stereotypic features, which allowed their accurate diagnosis and distinction from extraneural cases. The intraneural cysts had tubular (rather than globular) appearances. They derived from the postero-inferior portion of the superior tibiofibular joint and followed the expected course of the articular branch on the posterior surface of the popliteus muscle. The cysts then extended intra-epineurially into the parent tibial nerves, where they contained displaced nerve fascicles. The extraneural cyst extrinsically compressed the tibial nerve but did not directly involve it. All cadaveric specimens demonstrated a small single articular branch, which derived from the tibial nerve to the popliteus. The branch coursed obliquely across the posterior surface of the popliteus muscle before innervating the postero-inferior aspect of the superior tibiofibular joint. CONCLUSIONS: The clinical, MRI and anatomic features of tibial intraneural ganglion cysts are the posterior counterpart of the peroneal intraneural ganglion cysts arising from the anterior portion of the superior tibiofibular joint. These predictable features can be exploited and have implications for the pathogenesis of these intraneural cysts and treatment outcomes. These ganglion cysts are joint-related and provide further evidence to support the unifying articular theory. In each case the joint connection needs to be identified preoperatively, and the articular branches and the superior tibiofibular joint should be addressed operatively to prevent cyst recurrence.
Adult↗
Autogenous bone and hydroxyapatite cement for reconstruction of frontal bone defect.
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Bone Cements↗
A novel endoscopic technique in treating single nerve entrapment syndromes with special attention to ulnar nerve transposition and tarsal tunnel release: clinical application.
OBJECTIVE: To describe a simple retractor integrated endoscopic technique for treating idiopathic solitary compression neuropathies with special attention to the anterior transposition of the ulnar nerve and tarsal tunnel release, and to present the clinical results. METHODS: Eleven patients with ulnar sulcus syndrome, eight with tarsal tunnel syndrome, and one with meralgia paraesthetica (seven females and 13 males; age range, 12-64 yr) were treated with endoscopic anterior ulnar nerve transposition and in situ decompression of the tibial (eight patients) and lateral femoral cutaneous nerves (one patient), respectively. The selection criteria were: classical nerve compression symptoms, failed conservative treatment, abnormal electrophysiology, and a nonviolated anatomic region. The degree of nerve compression (after Dellon) was rated as moderate in five out of 20 patients and as severe in 15 out of 20 patients. Electrophysiological studies were conducted independently by physicians specializing in these techniques. Postoperative recovery was evaluated according to the nine-point Bishop rating system. RESULTS: Of the 11 patients with anterior ulnar nerve transposition, seven scored excellent, three scored good, and one scored fair (mean follow-up, 15.5 mo; range, 6-27 mo). Five patients with tarsal tunnel release scored excellent and three scored good (mean follow-up, 10.1 mo; range, 3-24 mo). The patient with meralgia paraesthetica showed an excellent score at 28 months after surgery. There were no technical or postoperative complications. None of the operations had to be converted to open surgery. CONCLUSION: We describe a new endoscopic technique for transposing the ulnar nerve and decompressing the tibial nerve. This technique could be extrapolated to release other single nerve entrapments. The simplicity of the technique, and our preliminary clinical results, may encourage other groups to adapt this method.
Adolescent↗
The role of near-infrared angiography in the assessment of post-operative venous congestion in random pattern, pedicled island and free flaps.
Indocyanine green near-infrared-video angiography (ICG-NIR-VA) was recently introduced for measuring perfusion of skin flaps. The prognostic value of this method with regards to post-transfer manipulations of the flap, and subsequently, flap survival is not adequately documented in the literature. In this paper, we report our experience with the ICG-NIR-VA in the intraoperative evaluation and post-operative follow-up of nine flaps (2 large random pattern, 4 pedicled island and 3 free flaps) used in various reconstructive procedures. Two flaps (1 random pattern and 1 free flap) showed delayed intraoperative uptake in ICG-NIR-VA. In the post-operative phase, (days 1-3) six flaps (1 random pattern, 2 axial pattern and 3 free flaps) showed a delay both in the ICG-NIR-VA uptake, as well as clearance. However, a clinical correlate was observed only in 2 of the 6 flaps demonstrating this delay: general and partial venous congestion was seen in a distally based interosseous posterior flap and a free lateral arm flap respectively. Leeches were implemented only based on the clinical signs. In one distally based perforator flap, the decision on perfusion augmentation via microanastomosis was based on the intraoperative ICG-NIR-VA finding. All flaps showed uneventful healing. Based on our observations, the question arises, not whether the ICG-NIR-VA is sensitive for the prognosis of venous congestion, upon which the flap manipulation strategy might rest-but whether it is too sensitive. Further, prospective studies are necessary.
Coloring Agents↗
Coverage of painful peripheral nerve neuromas with vascularized soft tissue: method and results.
OBJECTIVE: Our goals are to describe a method of treating painful peripheral nerve neuromas by means of vascularized tissue coverage, report the results in seven patients, and discuss the indications for this treatment modality. An analysis of pain, functionality of the affected body part, professional activities of the patients, and medications before and after surgery is presented. METHODS: Seven male patients (mean age, 45.1 yr) with posttraumatic nerve injuries, who had developed painful stump neuromas or neuromas-in-continuity, and who had unsuccessfully undergone several treatment procedures, were selected for the surgery described here. The operation included resection of the stump neuroma (four patients) or neurolysis of the neuroma-in-continuity (three patients) and coverage of the nerve with a vascularized fascial, fasciocutaneous, or perforator flap (three pedicled regional flaps and four free flaps). A modified quadruple visual analog scale was used to quantify pain before and after surgical treatment. The mean follow-up was 16.6 months. RESULTS: The mean values of the quadruple visual analog scale (pain now/typically/at its best/at its worst) before surgery were 6.5/6.5/4.7/7.9. These values changed to 0.3/0.4/0/0.9 at a mean follow-up of 16.6 months after surgery. Five patients returned to their original profession, one receives a pension, and one began a less demanding job after undergoing surgery. Six of the seven patients received opioids before surgery (one had a spinal cord stimulator). After surgery, all patients stopped taking regular pain killers and the spinal cord stimulator was deactivated in one; two patients still take nonsteroidal anti-inflammatory drugs occasionally, but not on a regular basis. CONCLUSION: Vascularized soft tissue coverage of painful peripheral nerve neuromas seems to be an effective and attractive, but also complex, method of treatment. This option may be considered and reserved for patients who have already undergone several pain treatment modalities without success.
Adult↗
A novel minimally occlusive microvascular anastomosis technique using a temporary intraluminal shunt: a prospective technique to minimize brain ischemia time during superficial temporal artery-to-middle cerebral artery bypass.
OBJECTIVE: To describe a new technique of suturing microvessels with persistent perfusion via a temporary intraluminal microshunt. METHODS: Experiments were conducted in Wistar rats. Abdominal aorta grafts were explanted from donor rats. A soft silicon microcatheter was introduced into the lumen of this graft. The abdominal aorta of a recipient rat was prepared for end-to-side microvascular anastomosis. Acland clamps (S&T AG, Neuhausen, Switzerland) were applied, and a linear arteriotomy was made. One end of the graft-clad microcatheter was introduced into the lumen and occluded with a fenestrated Acland clamp. At a more distal part, a similar arteriotomy was performed, and the other end of the microcatheter was introduced into the lumen and clamped with a fenestrated Acland clip. This created a temporary shunt through the graft-clad microcatheter. Then, the graft was anastomosed to the arteriotomies at both ends, over the microcatheter, in an end-to-side manner. The microcatheter was explanted from the vessel lumen through an arteriotomy in the middle of the graft. The graft was clipped short to close this arteriotomy. The mean total occlusion time before perfusion was reestablished amounted to 3.7 minutes. This experiment was repeated in 12 animals (6 with and 6 without heparin) without technical complications. As controls, conventional anastomoses were made in 2 animals. RESULTS: Suturing microvessels mandates their occlusion during the period of anastomosis. Although ischemia is well tolerated by other tissue types, the brain is quite sensitive to even short windows of ischemia. Nonocclusive anastomotic techniques have been developed recently. These are confined to vessels with luminal diameters greater than 3 mm. We have evolved a novel technique that can be used with microvessels, as pertinent to superficial temporal artery-to-middle cerebral artery bypass. CONCLUSION: We have described a new technique for performing microvascular anastomoses over a temporary intraluminal microcatheter shunt.
Anastomosis, Surgical↗
Simple and viable in vitro perfusion model for training microvascular anastomoses.
In this report, we describe a novel in vitro perfused microvessel model for training microvascular anastomotic exercises. Arteries and veins with a diameter of ca. 1 mm were explanted from chicken wings. These vessels were cannulated at both ends and mounted on a platform. Preserved, expired whole blood obtained from the blood bank was continuously injected through the proximal catheter, using an automatic perfusor. This in vitro perfused microvessel model exactly simulated the viable small-animal vessels. The setting is very simply and reliably repeated; the materials used are very cheap and universally available. There are no ethical questions involved. Vessels explanted from the human placenta or omentum may be used in a similar manner to gain the "feel" of functioning human microvascular tissue. But such materials are rarer and require the approval of ethical committees.
Anastomosis, Surgical↗
Near-infrared angiography and prediction of postoperative complications in various types of integumentary flaps.
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Angiography↗
Endoscopic exploration of the brachial plexus: technique and topographic anatomy--a study in fresh human cadavers.
OBJECTIVE: The indications for and timing of brachial plexus exploration in closed injuries are controversial. The time-consuming surgery proves its worth in some cases, whereas spontaneous regeneration might have been possible in others. The differentiation is difficult, because no investigational method reveals the exact morphological correlates of the nerve lesions. Minimally invasive, direct observation of the structures is a possible solution. Here we describe our surgical technique and the anatomic features of the normal brachial plexus appreciated with the endoscope. METHODS: Twenty-one brachial plexus in 11 fresh cadavers were investigated. Endoscopic exploration was performed at the supraclavicular and infraclavicular levels. The method involves insertion of an optic shaft-integrated retractor through a stab wound; retraction of landmark muscles produces a working space, into which other instruments are introduced for dissection. After completion of endoscopic surgery, open dissection was performed to verify the endoscopically identified structures and to assess iatrogenic injuries. RESULTS: The omohyoid muscle is a reliable landmark in the supraclavicular region, beneath which the suprascapular nerve can be observed. Following the suprascapular nerve proximally leads to the plexus trunks. Infraclavicular exploration first reveals the axillary artery. The plexus and its nerves are traced around this artery. The anatomic features were constant in all cases, with variations in fat accumulation depending on the corporeal constitution. We detected iatrogenic injuries to the medial circumflex humeral vessels in two cases. No nerve injuries were observed. CONCLUSION: The endoscopic technique combined with intraoperative nerve stimulation studies might provide important information on the type of morphological damage in closed brachial plexus injuries and thus might become an important tool for determination of the surgical treatment strategy. Clinical work is under way.
Aged↗
Pavlov and Cushing.
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Conditioning, Classical↗
Intraneural ganglion cysts: a case of sciatic nerve involvement.
The pathogenesis of intraneural ganglion cysts is unknown. Some authors have established a connection between the cysts and the joint, while others have failed to find this communication. Most intraneural ganglion cysts occur in the proximity of a joint. We present the case of a 53-year-old Caucasian male with an intraneural cyst of the sciatic nerve located high above its bifurcation and without a connection to the joint. The lesion was microsurgically removed in toto. There was no recurrence of the cyst at follow-up 9 months postoperatively; complete resolution of the clinical symptoms occurred within 8 months of surgery. This case shows that ganglion cysts can occur in locations far from a joint, supporting the extra-articular embryonic synovial remnant theory of their genesis.
Cysts↗
The application of rapid prototyping techniques in cranial reconstruction and preoperative planning in neurosurgery.
The value of rapid prototype models of the skull in our craniofacial and neurosurgical practice was analyzed. Individual skull models of 52 patients were produced by means of rapid prototyping techniques and used in various procedures. Patients were divided into three groups as follows: group I (26 patients) requiring corrective cranioplasty 1) after resection of osseous tumors (15 patients) and 2) with congenital and posttraumatic craniofacial deformities (11 patients), group II (10 patients) requiring reconstructive cranioplasty, and group III (16 patients) requiring planning of difficult skull base approaches. The utility of the stereolithographic models was assessed using the Gillespie scoring system. The esthetic and clinical outcomes were assessed by means of the esthetic outcome score and the Glasgow Outcome Score, respectively. Simulation of osteotomies for advancement plasty and craniofacial reassembly in the model before surgery in group I reduced operating time and intraoperative errors. In group II, the usefulness of the models depended directly on the size and configuration of the cranial defect. The planning of approaches to uncommon and complex skull base tumors (group III) was significantly influenced by the stereolithographic models. The esthetic outcome was pleasing. The indications for the manufacture of individual three-dimensional models could be cases of craniofacial dysmorphism that require meticulous preoperative planning and skull base surgery with difficult anatomical and reconstructive problems. The stereolithographic models provide 1) better understanding of the anatomy, 2) presurgical simulation, 3) intraoperative accuracy in localization of lesions, 4) accurate fabrication of implants, and 5) improved education of trainees.
Adolescent↗
Ventral cervical fusion at multiple levels using free vascularized double-islanded fibula - a technical report and review of the relevant literature.
Reconstruction of the cervical spine using free vascularized bone flaps has been described in the literature. The reports involve either one level or, when multiple levels, they describe en bloc resection and reconstruction. Stabilization of different levels with a preserved intermediate segment with a single vascularized flap has not been described. We report on the case of a 55-year-old man, who had been operated several times using conventional techniques for cervical myelopathy and instability, who presented to us with severe neck pain. Diagnostic procedures showed pseudarthrosis of C3/4 and stress-overload of the C3/4 and C5/6 segments. The C4/5 fusion was adequately rigid, but avascular. We performed anterior cervical fusion at the C3/4 and C5/6 levels with a vascularized fibula flap modified as a double island. The rigidly fused C4/5 block was preserved and vascularized with the periosteum bridging the two fibular islands. The method and technique are described in detail. Fusion was adequate. Donor site morbidity was minimal and temporary. The patient is symptom free to date (25 months). The suggested method provides the possibility of vertebral fusion at different levels using a single vascularized flap. The indications for this procedure are (1) repeated failure of conventional methods, (2) established poor bone healing and bone non-union with avascular grafts and (3) a well-fused or preserved intermediate segment. The relevant literature is reviewed.
Bone Plates↗