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PubMed1991

Interlocking intramedullary nailing for supracondylar and intercondylar fractures of the distal part of the femur.

Thirty-seven fractures of the distal part of the femur in thirty-five patients were treated with interlocking intramedullary nailing. All fractures were nailed by a closed technique after any intercondylar extension of the fracture had been managed by reduction and stabilization with percutaneous lag-screws. Patients who had an isolated condylar fracture or a severely comminuted intercondylar fracture were treated with other types of implants. There were thirty extra-articular (type-A) fractures and seven intra-articular (type-C1 and type-C2) fractures. Postoperatively, early mobilization exercises and weight-bearing were begun. At an average duration of follow-up of 20.5 months (range, fifteen to twenty-six months), all thirty-seven fractures had healed. There were no malunions of either the supracondylar or the intercondylar fractures. Complications were infrequent and included chronic irritation from the distal screws in three patients and delayed union in one; the latter healed with two centimeters of shortening after bone-grafting. There were no infections. The functional results were assessed with the modified knee-rating system of The Hospital for Special Surgery. Thirteen knees (35 per cent) had an excellent result; twenty-two (59 per cent), a good result; and two (5 per cent), a fair result. The results correlated with the age of the patient and the presence of an intra-articular fracture. We concluded that closed interlocking intramedullary nailing is an excellent technique for both supracondylar and simple intercondylar fractures in which closed reduction and percutaneous fixation of the articular fracture is possible.

Adult↗

PubMed1985

Repair of the flexor pollicis longus.

There are more repair techniques available for an injured flexor pollicis longus than for the other digital flexors. The procedure of choice is immediate primary or early delayed repair (less than three weeks after injury) by direct end-to-end suture. Good thumb function can also be obtained with the use of late delayed repair by tendon advancement with or without lengthening, free tendon grafting, and tendon transfer.

Humans↗

PubMed1995

Obstetrical palsy: early treatment and secondary procedures.

Obstetrical palsy has been described since a long time. Unfortunately, until the last 20 years, few options were available to correct its sequelae. During the last two decades, there has been a regain of interest because of the possibility to microsurgically repair these lesions. Tassin in 1984 demonstrated that babies who have no recovery of the biceps function by three months of age should be operated without delay. At brachial plexus exploration, in the presence of neuroma, nerve grafting is usually necessary. In cases of root avulsion, internal or external neurotization should be performed depending on the severity of the lesions. Physiotherapy and long-term follow-up of these patients are primordial to prevent joint ankylosis and to identify the patients who will benefit from secondary surgery. Our results are presented either after early treatment or after secondary procedures. These results justify aggressive management of obstetrical brachial plexus palsy because of children's great capacity for regeneration and accommodation.

Ankylosis↗

PubMed1998

Efficacy of endoventricular patch plasty in large postinfarction akinetic scar and severe left ventricular dysfunction: comparison with a series of large dyskinetic scars.

BACKGROUND: Many believe that dyskinesia is the only predictor of favorable surgical outcome after large myocardial infarction and that akinetic scars do not recover well in patients with globally depressed ventricular function. METHODS: This study evaluates clinical and hemodynamic results of endoventricular circular patch plasty in patients with either large akinetic scar (n = 51) or large dyskinetic scar (n = 49) and depressed left ventricular function (ejection fraction <30%). Groups were comparable for symptoms, indication for operation, and delay from myocardial infarction. Heart failure was a major indication for operation in both groups. Coronary grafting was performed in 98% of patients: 10 had mitral valve repair or replacement, and 47 patients with preoperative ventricular arrhythmias had cryotherapy. In-hospital mortality was 12% (five patients in the akinetic group [10%] and seven in the dyskinetic group [14%]). RESULTS: Results showed an early and late improvement in New York Heart Association functional class and ejection fraction (from 23% +/- 5% to 31% +/- 11% to 40% +/- 13% in akinetic patients and from 23% +/- 6% to 41% +/- 10% to 41% +/- 12% in dyskinetic patients). Ventricular tachycardia was reduced significantly in both groups early and late after the operation. CONCLUSION: We conclude that in patients with either large akinetic or dyskinetic scar and severe left ventricular dysfunction, endoventricular circular patch plasty associated with coronary grafting and cryotherapy, when indicated, provides surviving patients with significant improvement in cardiac function. This approach can be considered as an alternative to heart transplantation in patients with severe left ventricular dysfunction.

Cardiac Output↗

PubMed1986

The dependence of nerve regeneration through muscle grafts in the rat on the availability and orientation of basement membrane.

Nerve regeneration through grafts of basement membrane matrix, prepared by freezing of autogenous muscle followed by thawing in distilled water, was investigated in Sprague-Dawley rats. Electrophysiological evidence of recovery in distal nerve was observed at 51 days after implantation of treated grafts whose basement membrane tubes were coaxial with the proximal and distal ends of the transected sciatic nerve. This correlated with histological findings of well-developed myelinated nerve fibres within both grafts and distal nerve. However, whereas normal axon numbers were achieved in the grafts by 3 months, the regenerating nerve in these muscle grafts took 6 months to 1 year to recover normal axon diameter and myelination. Recovery was delayed through grafts whose basement membrane tubes were at right angles to the nerve fibres and through grafts of untreated muscle coaxially aligned. It is concluded that successful repopulation of the distal stump and functional recovery can follow nerve regeneration through treated muscle autografts. The rate of regeneration is dependent on the availability of empty basement membrane tubes. If these are unavailable or inappropriately orientated, regeneration can still occur but is significantly delayed.

Animals↗

PubMed2005

The renal-sparing efficacy of basiliximab in adult living donor liver transplantation.

The purpose of this study is to find out whether basiliximab administration will improve postoperative renal function by delaying the start of tacrolimus and decreasing of dosage requirement for tacrolimus in adult living donor liver transplantation (LDLT). Forty-five adult LDLT recipients were enrolled in the study. The induction group (n = 27) was given basiliximab 20 mg on days 0 and 4; tacrolimus administration was delayed until renal function improved. The control group (n = 18) did not receive basiliximab; tacrolimus was given on the first postoperative day. Trough levels of tacrolimus in the induction and control groups were aimed to be maintained at 5-10 ng/ml and 10-15 ng/ml during the first week after transplant, respectively. The median follow-up was 22 months (range 10-34 months). The preoperative conditions were poorer in the induction group (Child C, 56% vs. 33%, P = 0.01; UNOS 2a, 15% vs. 0%, P = 0.02). The intraoperative blood loss was also higher in the induction group than in the control group (median 2,180 ml vs. 495 ml, P < 0.01). The median delay in tacrolimus administration in the induction group was 36 hours (range 24-108 hours). Serum creatinine levels at second and third postoperative months were significantly lower in the induction group. The creatinine clearance rate in the induction group was higher at the third month posttransplant (median 72 vs. 57 ml/minute, P = 0.04). The incidence of renal insufficiency was significantly lower in the induction group at the third month posttransplant (26% vs. 67%, P < 0.01). Blood cholesterol level at the sixth month posttransplant was lower in the induction group (median 152 vs. 196 mg/dl P = 0.03). The incidences of acute cellular rejection, bacteremia, and cytomegalovirus (CMV) infection were similar in both groups. In conclusion, for pretransplant critical patients with more intraoperative blood loss, basiliximab induction could prevent early renal dysfunction by delaying the start of tacrolimus and reducing the dose requirement of tacrolimus without increasing graft rejection and infection. Furthermore, it also improved renal function as well as lowered cholesterol levels within 6 months after transplantation.

Adult↗

PubMed2005

Myocardial viability assessment in patients with highly impaired left ventricular function: comparison of delayed enhancement, dobutamine stress MRI, end-diastolic wall thickness, and TI201-SPECT with functional recovery after revascularization.

This study compared different magnetic resonance imaging (MRI) methods with Tl(201) single photon emission computerized tomography (SPECT) and the "gold standard" for viability assessment, functional recovery after coronary artery bypass grafting (CABG). Twenty patients (64+/-7.3 years) with severely impaired left ventricular function (ejection fraction [EF] 28.6+/-8.7%) underwent MRI and SPECT before and 6 months after CABG. Wall-motion abnormalities were assessed by stress cine MRI using low-dose dobutamine. A segment with a nonreversible defect in Tl(201)-SPECT and a delayed enhancement (DE) in an area >50% of the entire segment, as well as an end-diastolic wall thickness <6 mm, was defined as nonviable. The mean postoperative EF (n=20) improved slightly from 28.6+/-8.7% to 32.2+/-12.4% (not significant). Using the Tl(201)-SPECT as the reference method, end-diastolic wall thickness, MRI-DE, and stress MRI showed high sensitivity of 94%, 93%, and 84%, respectively, but low specificities. Using the recovery of contractile function 6 months after CABG as the gold standard, MRI-DE showed an even higher sensitivity of 99%, end-diastolic wall thickness 96%, stress MRI 88%, and Tl(201)-SPECT 86%. MRI-DE showed advantages compared with the widely used Tl(201)-SPECT and all other MRI methods for predicting myocardial recovery after CABG.

Aged↗

PubMed2004

Should living-unrelated renal transplant recipients receive antibody induction? Results of a clinical experience trial.

BACKGROUND: Living-donor kidney transplant recipients generally do not receive antibody induction. Induction avoidance may not be appropriate, particularly for living-unrelated renal transplant (LURT) recipients, in whom matching may not be optimal. We compared the incidence of acute rejection and graft outcome of LURT recipients who were administered no induction and cadaveric renal transplant (CRT) recipients who were administered anti-CD25 antibody. These groups both had immediate graft function and similar maintenance immunosuppression. METHODS: This retrospective analysis included patients who received kidney transplants between 1999 and 2000. CRT recipients received basiliximab, corticosteroids, mycophenolate mofetil (MMF), and delayed tacrolimus (serum creatinine <3 mg/dL). LURT recipients received tacrolimus (initiated pretransplantation), MMF, and corticosteroids. RESULTS: The analysis included 136 LURT recipients and 126 CRT recipients. CRT recipients included more African Americans (52.4% vs. 30.9%, P<0.01). LURT recipients included more patients with at least one human leukocyte antigen mismatch (97.8% vs. 85.7%, P<0.01). A higher acute rejection rate was observed in LURT recipients at both 6 months (LURT recipients 19.1% vs. CRT recipients 3.2%, P<0.01) and 1 year (21.3% vs. 4.0%, P<0.0004); a higher rate also was observed in African American LURT recipients compared with African American CRT recipients (35.7% vs. 4.5%, P<0.0015) at 1 year. LURT recipients demonstrated a threefold greater rejection risk than CRT recipients who were administered basiliximab (relative risk: 3.6, P<0.002). Graft survival was similar at 1 year. CONCLUSION: The higher rejection rates in LURT recipients (no induction) compared with CRT recipients (basiliximab induction), despite similar chronic immunosuppression (tacrolimus, MMF, and steroids) and immediate graft function, indicate the potential advantage of anti-CD25 induction in LURT protocols to reduce the risk of acute rejection.

Black or African American↗

PubMed1996

Antioxidant lazaroid U-74006F improves renal function and reduces the expression of cytokines, inducible nitric oxide synthase, and MHC antigens in a syngeneic renal transplant model. Partial support for the response-to-injury hypothesis.

In a recent study, antioxidant therapy at the time of renal transplantation in humans was associated with fewer rejection episodes and extended graft survival. A hypothesis generated by such studies and based on the response-to-injury model is that reducing the oxidative injury during transplantation may dampen certain cellular responses to injury that are important in triggering allograft rejection. To test whether ablation of oxidative injury would limit such responses, kidneys were transplanted between Wistar-Furth rats, with and without antioxidant 21-aminosteroid. 21-Aminosteroid was administered before kidney harvest and, again, before transplant reperfusion. The recipient's left kidneys, removed to accommodate the donor kidneys, were used as normal control. The removal of the right kidneys contralateral to the transplant were delayed to day 4 to provide interim renal support. The transplanted kidneys were harvested on day 7. Administration of 21-aminosteroid was associated with better graft function and reduced lipid peroxidation. Compared with the normal control kidneys, the kidneys transplanted with vehicle had higher cytokine mRNA levels (measured by reverse transcriptase-polymerase chain reaction) for interleukin 2, interleukin 6, tumor necrosis factor-alpha, and interferon-gamma. The levels for these cytokines were reduced in kidneys transplanted with 21-aminosteroid. An increase in inducible nitric oxide synthase mRNA in the transplanted kidney was inhibited by 21-aminosteroid, as were the increase in class I and II MHC antigens. The new finding, that a reduction in transplantation-related oxidative injury in a syngeneic model is accompanied by a reduction in the expression of cytokines, MHC antigens, and inducible nitric oxide synthase, provides partial support for the response-to-injury hypothesis in the setting of renal transplantation. The data also demonstrate for the first time the efficacy of 21-aminosteroid to reduce lipid peroxidation and renal injury in kidneys transplanted after cold preservation.

Animals↗

PubMed1988

Transplantation of cryogenically preserved mandibular condyles in the adult and juvenile goat.

Loss of a functional temporomandibular joint (TMJ), due to various causes including tumor resection, joint disease such as osteonecrosis, and injury or trauma, has long been a clinical challenge in both children and adults. It may be a significant problem facing physicians during another war. While reconstruction to date has been performed with various prosthetic devices or autogenous costochondral grafts, these procedures have a potential for complications and morbidity. This procedure could adversely delay the return of military members to a combat unit, or affect their ability to serve as functional members of society. Our studies were performed to determine the feasibility of TMJ reconstruction techniques, healing, and long-term function and growth using cryogenically preserved mandibular allografts in the goat. This species was chosen because the surgical anatomy and biomechanics of the goat TMJ are very similar to that of the human. The positive results of the studies and their relevance to future military medical readiness and civilian medicine will be described.

Age Factors↗

PubMed1999

Complete traumatic brachial plexus palsy. Treatment and outcome after repair.

Seventy-eight patients who had a complete brachial plexus palsy caused by a stretching injury were operated on by the same surgeon between January 1980 and December 1991. The aim of the operative intervention was to obtain the best functional result, including at the level of the hand, that was possible in view of the initial lesions and the intraoperative findings. Therefore, the treatment strategy included not only nerve repair with grafting (124 grafts) or nerve transfer (twenty-seven transfers) but also palliative procedures, the latter of which sometimes were performed several years later. Sixty-three patients were evaluated by an independent observer at least three years postoperatively. The results associated with each type of lesion and each type of nerve repair were assessed according to the function of the muscles that were innervated by the recipient nerve. Six patients had a neurolysis only. The remaining fifty-seven patients had grafts or nerve transfers to repair the biceps. Thirty-six of the fifty-seven received a rating of 3+ or more (meaning that the patient was able to flex the elbow repeatedly); the remaining twenty-one received a rating of 3 or less (meaning that the patient was able to flex the elbow only once or not at all), which we considered unsatisfactory. The function of the triceps recovered after eleven of thirty-one procedures that were performed to restore that nerve; that of the extensor carpi radialis, after five of thirty-one procedures; that of the flexor carpi radialis, after six of thirty-one procedures; and that of the flexor digitorum, after four of thirty-one procedures. A statistical analysis revealed that an operative delay of less than six months was a significant factor with respect to recovery of the function of the biceps (p = 0.003). The thirty-nine grafts that were sutured onto the lateral or posterior cord produced better results than did the thirty-six that were sutured onto the distal branches (the musculocutaneous and radial nerves); however, with the numbers available, this difference was not found to be significant (p = 0.08). Eleven patients had a successful result (a rating of 3+ or more) and eight, a fair or poor result, with respect to recovery of biceps function after transfer of the spinal accessory nerve to the musculocutaneous nerve. Overall, twenty-nine patients had relief of pain postoperatively. Sixteen patients had grade-3 pain preoperatively compared with only three after the operation. According to a self-rating scale, twenty-five patients were satisfied with the overall result, sixteen were fairly satisfied, and twenty-two were dissatisfied.

Adult↗

PubMed1980

A new method of oral reconstruction using a free composite foot flap.

We present a series of 10 free composite foot flaps used in 9 patients for floor-of-mouth and mandible reconstruction after composite resection. This one-stage repair replaces the soft tissue as well as the bone that has been resected. The flap is easily obtained from the foot, and is tailored to meet the requirements of the mouth and jaw defect. Donor site morbidity is surprisingly low: two flaps were lost from vascular obstruction, and 1 from delayed infection at ten days. The surviving flaps have provided good cosmetic and functional results. Bony union has occurred in half the grafts, and satisfactory firm fibrous union in the remainder. The flap is also useful for late reconstruction in "oral cripples," and may be used with the skin internally or externally as required. We are pleased with the versatility of this flap in complicated reconstructions.

Female↗

PubMed1981

Interaction of macrophages and lymphocytes in rat skin allografts.

Light microscopy of 2 microgram sections of rejecting rat skin allografts, embedded in hydroxyethyl methacrylate, revealed among the cells infiltrating the graft base extravascular macrophages containing a small lymphocyte. Toluidine blue staining indicated DNA degradation in some of these phagocytosed lymphocytes. More frequently small lymphocytes were in intimate contact with the surface of the macrophages, resembling "Periopolesis', which others have previously observed in vitro. These macrophage-lymphocyte interactions were not seen in sections of autografts. Despite a previous report that diphenylhydantoin (phenytoin) impairs macrophage function, these macrophage-lymphocyte interactions were present in grafts placed in rats receiving this drug. This treatment did not hasten or delay the onset of graft rejection. These in vivo findings both accord with recent in vitro studies on the mechanisms of phagocytosis and with reports that phagocytosis is one of the effector mechanisms in allograft rejection. However, macrophage phagocytosis of lymphocytes has also been observed in testicular lymph collected from conscious normal sheep.

Animals↗

PubMed1995

Tibial fractures with bone loss treated by primary reamed intramedullary nailing.

We reviewed the results of the treatment of 30 tibial fractures with minor to severe bone loss in 29 patients by early soft-tissue and bony debridement followed by primary locked intramedullary nailing. Subsequent definitive closure was obtained within the first 48 hours usually with a soft-tissue flap, and followed by bone-grafting procedures which were delayed for six to eight weeks after the primary surgery. The time to fracture union and the eventual functional outcome were related to the severity and extent of bone loss. Twenty-nine fractures were soundly united at a mean of 53.4 weeks, with delayed amputation in only one patient. Poor functional outcome and the occurrence of complications were usually due to a departure from the standard protocol for primary management. We conclude that the protocol produces satisfactory results in the management of these difficult fractures, and that intramedullary nailing offers considerable practical advantages over other methods of primary bone stabilisation.

Activities of Daily Living↗

PubMed1993

Microsurgical reconstruction in limb-salvage procedures: comparison between primary and secondary reconstruction.

Limb-salvaging procedures after malignant tumor resection in the extremities were performed in 22 cases, utilizing microsurgical tissue transplantation. Five patients had soft-tissue tumors and 17 had bone tumors. Thirteen cases were primarily and nine were secondarily reconstructed. The advantages and disadvantages of both primary and secondary reconstructions were compared: as to technical difficulty, primary reconstruction was much easier. Chemotherapy was necessary just before and/or after reconstruction in eight of 13 cases of primary reconstruction. Delayed union or non-union occurred more frequently in patients who required chemotherapy, but eventual union was achieved in all cases by adding a conventional bone graft. As for oncologic and functional status, there was no difference in oncological status between the primary and secondary groups, but the primary reconstructions showed better functional results. Although individualized treatment is of utmost importance when utilizing microsurgical reconstruction to save limbs, primary reconstruction can be done most successfully when there is a wide surgical margin after tumor resection and when attention is paid to the avoidance of such complications as delayed union or non-union.

Adolescent↗

PubMed1993

The results of secondary microsurgical repair of ulnar nerve injury.

110 patients with injuries to the ulnar nerve were assessed, on average, 12.7 (3-20) years after secondary repair. 89 were male and 21 female, with a mean age of 27.9 years. Most of the nerve lesions were sharp (63) or blunt (41) injuries. Division was total in 76 cases and most were at the forearm level. The average delay from the injury to the operation was 10.1 (1-48) months. Secondary repair was performed in 34 cases and fascicular grafting in 76 cases. The mean graft length was 5.4 (1-30) cm. Four factors of motor and sensory function were assessed and the quantitative evaluation was compared with the MRC classification. Useful results were obtained in only 51.8% and poor in 30.9%. The age of the patient, the width of contusion, the pre-operative delay, and the level of the injury influenced the results significantly.

Adolescent↗

PubMed2004

Delayed primary closure of the burn wounds.

'Early closure' of burn wounds by excising the burned tissues and promptly covering it with skin-grafts or its substitutes within first 'five' post-burns day is a standard technique of burn-wound-management in the burn-units of the "developed" world. But lack of education in general, and health-education in particular amongst the common people in the "developing" countries could hinder acceptance of this procedure. Lack of well-trained and motivated burns-surgeons could worsen the situation. The Sultanate of Oman is one of the developing gulf-countries in the middle-east, where at Khoula hospital, the National Burns-Center in the capital city of Muscat, 'early' surgery was introduced in November 1997 to soon become a routine protocol for burn-wound-management. But delay in getting consent for surgery from unwilling patients or in transferring them from the peripheral hospitals were often the reasons for delaying the burn-wound excision and closure 'beyond 6 days to 11th or 12th' day post-burn. Hence, instead of the term "early", the authors prefer to call it "delayed primary" burn-wound closure because, it still offers "primary intention healing" of the burn-wounds. The aim of this article is to analyze retrospectively the results of the "delayed primary" closure of the burn-wounds done in the Khoula Hospital Burns-Unit of the Sultanate of Oman. During a period of 50 months from November 1997 to December 2001, carefully selected 143 patients out of a total of 592 admissions in burns-unit were subjected to burn-wound excision and auto-skin-grafting (STSG), of whom about 87% patients had "delayed primary" and 13% had "early" surgery. There was no mortality or post-operative morbidity in these operated patients. However, due to the non-availability of skin substitutes the excision and auto-grafting could not be done in extensive burns with inadequate skin-donor-area. The maximum percentage of burns treated by delayed primary surgery (DPS) was 50% in children and 55% in adults. Follow-up results were good functionally as well as cosmetically. The authors conclude that "delayed primary" is the second best alternative to the "early" burn-wound excision and closure with similar advantages of reducing risk of septicemia, mortality, and morbidity, hospital stay and cost of treatment. It should be preferred over "secondary" skin-grafting of granulating wounds. Thus, in the developing countries, the indications of delayed primary burn surgery could be (1) patients unstable or unfit for surgery during the first post-burn week; (2) delay in transferring in the patients; (3) delay in getting patient's consent for surgery; (4) very major burns without availability of skin substitutes; and (5) lack of operating time in a busy burns-unit. The contraindications for delayed primary surgery are any sign of invasive sepsis or organ failure.

Adolescent↗

PubMed1997

Humeral lengthening using the Ilizarov technique.

Significant shortening of the humerus may cause cosmetic, psychologic and functional problems. From 1989 to 1993, we performed humeral lengthening using the Ilizarov technique on six patients. The indications were: 1) significant inequality (> 4-14 cm); 2) significant functional impairment; and 3) poor aesthetic appearance or related psychologic problems. THere were three females and three males, with a mean age of 17.7 years. The right humerus was affected in two patients, the left in four. Etiologies included sequelae of neonatal septic shoulder in three patients, sequelae of childhood trauma in one, malunion in one and congenital bone anomaly in one. Mean shortening of the humerus was 9.2 cm. Total average treatment time was 250 days. Mean lengthening was 8.7 cm. Complications included transient radial nerve palsy in one patient and delayed union in another. Bone grafting was performed on the patient who sustained delayed union. Fracture of the distraction site occurred after removing the Ilizarov device, and open reduction and internal fixation was performed. Functional and aesthetic status was improved in all six patients, over a minimum of 2 years follow-up. Lengthening of the humerus can be performed satisfactorily using the Ilizarov technique.

Adolescent↗