Rod Hentz
Professor of Surgery, Emeritus
Surgery - Plastic & Reconstructive Surgery
Academic Appointments
-
Emeritus Faculty, Acad Council, Surgery - Plastic & Reconstructive Surgery
-
Member, Bio-X
Current Research and Scholarly Interests
1. Nerve regeneration and repair, evaluation of repair methods, modalities to enhance peripheral nerve regeneration, development of improved methods to analyze nerve regeneration.
2. Implementation of functional neuromuscular stimulation to paralytic deformities.
3. Computer modeling of upper limb function.
2023-24 Courses
-
Independent Studies (5)
- Directed Reading in Surgery
SURG 299 (Aut, Sum) - Graduate Research
SURG 399 (Aut, Sum) - Medical Scholars Research
SURG 370 (Aut, Sum) - Plastic Surgery Tutorial
SURG 208 (Aut, Sum) - Undergraduate Research
SURG 199 (Aut, Sum)
- Directed Reading in Surgery
All Publications
-
Electromyographic Analysis of Grip
ORTHOPEDICS
2019; 42 (6): E555–E558
Abstract
This prospective cohort study used video electromyography synchronized analysis to determine the dynamic use of extrinsic and intrinsic finger flexion during grasp. Light fist formation primarily involved the flexor digitorum profundus with either the flexor digitorum superficialis or intrinsics. In contrast, both the flexor digitorum superficialis and intrinsics were recruited in all tight fist video electromyography. However, the sequence of recruitment differed between patients in tight fist formation. Injured patients demonstrated a unique pattern of recruitment based on injury. The authors conclude that the flexor digitorum profundus is the workhorse in composite fist formation but the roles of the flexor digitorum superficialis and the intrinsic muscles are less consistent across patients. [Orthopedics. 2019; 42(6):e555-e558.].
View details for DOI 10.3928/01477447-20190812-06
View details for Web of Science ID 000498511000012
View details for PubMedID 31408520
-
Long-Term Outcomes of Brachial Plexus Reconstruction with Sural Nerve Autograft for Brachial Plexus Birth Injury.
Plastic and reconstructive surgery
2019; 143 (5): 1017e–1026e
Abstract
BACKGROUND: Infants with brachial plexus birth injury who do not recover motor function spontaneously in a timely manner are candidates for brachial plexus reconstruction with nerve autograft. Outcomes of this intervention are incompletely understood. The authors present the long-term outcomes of brachial plexus reconstruction with sural nerve autograft in infants with brachial plexus birth injury.METHODS: The authors retrospectively reviewed all infants with brachial plexus birth injury who underwent brachial plexus reconstruction with sural nerve autograft between 1992 and 2014 with a minimum 2-year follow-up. The authors used Active Movement Scale scores to determine the presence and timing of shoulder, elbow, and wrist recovery. They assessed recovery of hand function in infants with global brachial plexus birth injury with the Raimondi scale. The number and type of secondary reconstructive procedures were identified.RESULTS: Forty-three infants who underwent brachial plexus reconstruction at age 7 ± 2 months old were followed for 7 ± 5 years. Most infants recovered antigravity elbow flexion (91 percent) and shoulder abduction (67 percent), but fewer recovered antigravity shoulder external rotation (19 percent) and wrist extension (37 percent). Mean postoperative times until observed antigravity motor strength (Active Movement Scale score >5) at the shoulder, elbow, and wrist were all greater than 12 months; evidence of initial motor recovery (Active Movement Scale score >2) was observed earlier. The mean Raimondi score in infants with global brachial plexus birth injury was 2.2 (range, 0 to 5) at final follow-up. Thirty-three children underwent 2 ± 1.2 secondary reconstructive procedures.CONCLUSIONS: Brachial plexus reconstruction with sural nerve autograft reliably results in recovery of shoulder abduction and elbow flexion, but recovery of shoulder external rotation and wrist extension is less predictable, and recovery often takes more than 1 year. Secondary procedures are often performed to optimize function.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
View details for PubMedID 31033825
-
Long-Term Outcomes of Brachial Plexus Reconstruction with Sural Nerve Autograft for Brachial Plexus Birth Injury
PLASTIC AND RECONSTRUCTIVE SURGERY
2019; 143 (5): 1017E–1026E
View details for DOI 10.1097/PRS.0000000000005557
View details for Web of Science ID 000466117600012
-
Tendon transfers after peripheral nerve injuries: my preferred techniques.
The Journal of hand surgery, European volume
2019: 1753193419864838
Abstract
While there is now keen interest in restoring function lost through irreparable nerve injury by performing nerve-to-nerve transfer, for some time to come, tendon transfers will remain the primary reconstructive procedure for paralytic injuries of the upper limb. A career spanning more than 50 years has permitted the author to try many tendon transfers promoted by past and present colleagues for the three common nerve injuries (median, radial and ulnar) affecting hand function and, eventually, to settle upon those which have provided the most predictable and consistent outcomes. This article describes the author's preferred tendon transfers for high radial and low median and ulnar palsies, providing the rationale behind these choices, operative details supplemented with illustrations, technical tips and advice regarding postoperative rehabilitation.
View details for DOI 10.1177/1753193419864838
View details for PubMedID 31364477
-
The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap.
Hand (New York, N.Y.)
2018: 1558944717751191
Abstract
BACKGROUND: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion.METHODS: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap.RESULTS: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united.CONCLUSIONS: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.
View details for DOI 10.1177/1558944717751191
View details for PubMedID 29357702
-
A Double-Blind Placebo Randomized Controlled Trial of Minocycline to Reduce Pain After Carpal Tunnel and Trigger Finger Release.
journal of hand surgery
2017; 42 (3): 166-174
Abstract
Minocycline is a microglial cell inhibitor and decreases pain behaviors in animal models. Minocycline might represent an intervention for reducing postoperative pain. This trial tested whether perioperative administration of minocycline reduced time to pain resolution (TPR) after standardized hand surgeries with known prolonged pain profiles: carpal tunnel release (CTR) and trigger finger release (TFR).This double-blinded randomized controlled trial included patients undergoing CTR or TFR under local anesthesia. Before surgery, participants recorded psychological and pain measures. Participants received oral minocycline, 200 mg, or placebo 2 hours prior to procedure, and then 100 mg of minocycline or placebo 2 times a day for 5 days. After surgery, participants were called daily assessing their pain. The primary end point of TPR was when participants had 3 consecutive days of 0 postsurgical pain. Futility analysis and Kaplan-Meier analyses were performed.A total of 131 participants were randomized and 56 placebo and 58 controls were analyzed. Median TPR for CTR was 3 weeks, with 15% having pain more than 6 weeks. Median TPR for TFR was 2 weeks with 18% having pain more than 6 weeks. The overall median TPR for the placebo group was 2 weeks (10% pain > 6 weeks) versus 2.5 weeks (17% pain > 6 weeks) for the minocycline group. Futility analysis found that the likelihood of a true underlying clinically meaningful reduction in TPR owing to minocycline was only 3.5%. Survival analysis found minocycline did not reduce TPR. However, subgroup analysis of those with elevated posttraumatic distress scores found the minocycline group had longer TPR.Oral administration of minocycline did not reduce TPR after minor hand surgery. There was evidence that minocycline might increase length of pain in those with increased posttraumatic stress disorder symptoms.Therapeutic I.
View details for DOI 10.1016/j.jhsa.2016.12.011
View details for PubMedID 28259273
-
Lars Vistnes, MD, 1927 to 2016 OBITUARY
PLASTIC AND RECONSTRUCTIVE SURGERY
2016; 138 (6): 1382
View details for DOI 10.1097/PRS.0000000000002787
View details for Web of Science ID 000389033800064
-
Evaluation of a Task-Based Intervention After Tendon Transfer to Restore Lateral, Pinch
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2016; 97 (6): S144-S153
Abstract
To quantify changes in pinch force and brachioradialis (BR) activation after a task-based training program designed to improve pinch force after BR to flexor pollicis longus (FPL) transfer.One-group repeated-measures design compared pinch force and BR activation pre- and posttraining. Significant differences were tested with Wilcoxon signed-rank tests for pairwise comparisons at the P≤.05 level.Testing occurred in a Veterans Affairs Medical Center research laboratory and training was in a home setting.Participants with cervical spinal cord injury (SCI) and previous BR to FPL transfer were enrolled in the study (N=8). Six patients completed the training program and posttraining measures.The 10-week training was a home program that included novel activities to increase BR activation and practice producing pinch force in a variety of upper limb postures. Participants were provided with the task-based training equipment and instructed to practice 3 times per week.Fine-wire electromyography of the transferred BR was recorded in maximum effort pinch force (N). Secondary measures included the strength and activation of the antagonist elbow extensor.Pinch force increased 3.7N (.38kg) and BR muscle activation increased 10% (P≤.05) after the training. There was no increase in elbow extension strength, but participants with previous posterior deltoid to triceps transfer achieved greater activation of the antagonist elbow extensor.The findings from this pilot study suggest that outcomes of tendon transfer and conventional therapy can be improved for patients with chronic cervical SCI.
View details for DOI 10.1016/j.apmr.2015.12.032
View details for Web of Science ID 000377237200010
View details for PubMedID 27233589
-
Multicenter Survey of the Effects of Rehabilitation Practices on Pinch Force Strength After Tendon Transfer to Restore Pinch in Tetraplegia
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2016; 97 (6): S105-S116
Abstract
To identify key components of conventional therapy after brachioradialis (BR) to flexor pollicis longus (FPL) transfer, a common procedure to restore pinch strength, and evaluate whether any of the key components of therapy were associated with pinch strength outcomes.Rehabilitation protocols were surveyed in 7 spinal cord injury (SCI) centers after BR to FPL tendon transfer. Key components of therapy, including duration of immobilization, participation, and date of initiating therapy activities (mobilization, strengthening, muscle reeducation, functional activities, and home exercise), were recorded by the patient's therapist. Pinch outcomes were recorded with identical equipment at 1-year follow-up.Seven SCI rehabilitation centers where the BR to FPL surgery is performed on a routine basis.Thirty-eight arms from individuals with C5-7 level SCI injury who underwent BR to FPL transfer surgery (N=34).Conventional therapy according to established protocol in each center.The frequency of specific activities and their time of initiation (relative to surgery) were expressed as means and 95% confidence intervals. Outcome measures included pinch strength and the Canadian Occupational Performance Measure (COPM). Spearman rank-order correlations determined significant relations between pinch strength and components of therapy.There was similarity in the key components of therapy and in the progression of activities. Early cast removal was associated with pinch force (Spearman ρ=-.40, P=.0269). Pinch force was associated with improved COPM performance (Spearman ρ=.48, P=.0048) and satisfaction (Spearman ρ=.45, P=.0083) scores.Initiating therapy early after surgery is beneficial after BR to FPL surgery. Postoperative therapy protocols have the potential to significantly influence the outcome of tendon transfers after tetraplegia.
View details for DOI 10.1016/j.apmr.2016.01.036
View details for Web of Science ID 000377237200006
View details for PubMedID 27233585
-
Access to surgical upper extremity care for people with tetraplegia: an international perspective
SPINAL CORD
2015; 53 (4): 302-305
Abstract
Survey.To determine whether upper extremity reconstruction in patients with tetraplegia is underutilized internationally and, if so, what are the barriers to care.International-attendees of a meeting in Paris, France.One hundred and seventy attendees at the Tetrahand meeting in Paris in 2010 were sent a 13-question survey to determine the access and utilization of upper limb reconstruction in tetraplegic patients in their practice.Respondents ranged the globe including North America, South America, Europe, Asia and Australia. Fifty-nine percent of respondents had been practicing for more than 10 years. Sixty-four percent of respondents felt that at least 25% of people with tetraplegia would be candidates for surgery. Yet the majority of respondents found that <15% of potential patients underwent upper extremity reconstruction. Throughout the world direct patient referral was the main avenue of surgeons meeting patients with peer networking a distant second. Designated as the top three barriers to this care were lack of knowledge of surgical options by patients, lack of desire for surgery and poor referral patterns to appropriate upper extremity surgeons.The results of this survey, of a worldwide audience, indicate that many of the same barriers to care exist regardless of the patient's address. This was a preliminary opinion survey and thus the results are subjective. However, these results provide a roadmap to improving access to care by improving patient education and interdisciplinary physician communication.
View details for DOI 10.1038/sc.2015.3
View details for Web of Science ID 000352725500008
View details for PubMedID 25687516
-
Commentary Regarding "Risk Factors for Complications Following Open Reduction Internal Fixation of Distal Radius Fractures" and "Risk Factors for 30-Day Postoperative Complications and Mortality Following Open Reduction Internal Fixation of Distal Radius Fractures"
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2014; 39 (12): 2381–82
View details for DOI 10.1016/j.jhsa.2014.10.023
View details for Web of Science ID 000345557600004
View details for PubMedID 25459956
-
Multiple Collagenase Injections Are Safe for Treatment of Dupuytren's Contractures.
Orthopedics
2014; 37 (7): e657-60
Abstract
The authors report the case of a 65-year-old, right-hand-dominant man who had severe Dupuytren's disease with multiple cords and flexion contractures of the metacarpophalangeal and proximal interphalangeal joints of both hands and underwent repeated collagenase injections for treatment. Collagenase has been shown to be safe and effective in the treatment of Dupuytren's contractures when administered as a single dose, but the results of multiple injections over a prolonged period are unknown. Antibodies to collagenase develop in all patients after several treatments, raising concerns about safety and efficacy as a result of sensitization from repeated exposures. The antibodies generated as a result of repeated exposure to collagenase could theoretically render it less effective with time and could also lead to immune reactions as severe as anaphylaxis. The authors present the case of a single patient who experienced continued correction of his contractures with only minor and self-limited adverse reactions after administration of 12 collagenase doses through 15 injections during a 4-year period. Over time, the injections continued to be effective at correcting metacarpophalangeal joint contractures, but less effective at correcting proximal interphalangeal joint contractures. The patient did eventually require a fasciectomy, but the safety and modest success of the repeated collagenase injections shows promise for a less invasive treatment with a better risk profile than open fasciectomy. Although further studies are needed, repeated administration of collagenase appears to be safe and modestly effective for severe Dupuytren's contractures, although a fasciectomy may ultimately be required in the most severe cases.
View details for DOI 10.3928/01477447-20140626-64
View details for PubMedID 24992063
-
Technical Tips for Collagenase Injection Treatment for Dupuytren Contracture
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2014; 39 (6): 1195-1200
Abstract
We describe technical tips for injecting collagenase into Dupuytren cords based on experience acquired during the prerelease Food and Drug Administration clinical trials and with subsequent clinical practice. These tips include techniques for extracting the reconstituted enzyme efficiently from the vial, injecting the cord(s) with increased safety to the tendons, and anesthetizing the hand before manipulation. The tips are intended to supplement but by no means replace the manufacturer's prescribing information and training video.
View details for DOI 10.1016/j.jhsa.2014.03.016
View details for Web of Science ID 000337011000029
View details for PubMedID 24862115
-
Surgical Treatment of Trapeziometacarpal Joint Arthritis: A Historical Perspective
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
2014; 472 (4): 1184-1189
Abstract
The trapeziometacarpal (TMC) joint's unique anatomy and biomechanics render it susceptible to degeneration. For 60 years, treatment of the painful joint has been surgical when nonoperative modalities have failed. Dozens of different operations have been proposed, including total or subtotal resection of the trapezium or resection and implant arthroplasty. Proponents initially report high levels of patient satisfaction, but longer-term reports sometimes fail to support initial good results. To date, no one procedure has been shown to be superior to another.This review sought to identify factors responsible for the development of many different procedures to treat the same pathology and factors influencing whether procedures remain in the armamentarium or are abandoned.I performed a nonsystematic historical review of English-language surgical journals using the key words "carpometacarpal arthritis", or "trapeziometacarpal arthritis", and "surgery" in combination with "history" using the PubMed database. In addition, bibliographies of pertinent articles were reviewed.The factors that led to many surgical innovations appear to be primarily theoretical concerns about the shortcomings of previously described procedures, especially about proximal migration of the thumb metacarpal after trapezial resection. Longevity of a particular procedure seems to be related to simplicity of design, especially for prosthetic arthroplasty. The evolution of surgery for TMC joint arthritis both parallels and diverges from that in other joints. For example, for most degenerated joints (even many in the hand), treatment evolved from resection arthroplasty to implant arthroplasty. In contrast, for the TMC joint, the 60-year-old procedure of trapezial resection continues to be performed by a majority of surgeons; many modifications of that procedure have been offered, but none have shown better pain reduction or increased function over the original procedure. In parallel, many differently designed prosthetic total or hemijoint arthroplasties have been proposed and performed, again with as yet unconvincing evidence that this technology improves results over those obtained by simple resection arthroplasty.Many procedures have been described to treat TMC joint arthritis, from simple trapezial resection to complex soft tissue arthroplasty to prosthetic arthroplasty. In the absence of evidence for the superiority of any one procedure, surgeons should consider using established procedures rather than adopting novel ones, though novel procedures can and should be tested in properly designed clinical trials. Tissue-engineered solutions are an important area of current research but have not yet reached the clinical trial stage.
View details for DOI 10.1007/s11999-013-3374-z
View details for Web of Science ID 000332576400021
View details for PubMedID 24214823
View details for PubMedCentralID PMC3940734
-
Collagenase Injections for Treatment of Dupuytren Disease
HAND CLINICS
2014; 30 (1): 25-?
Abstract
Palmodigital fasciectomy remains the gold standard. The initial outcome is, in my experience, far more predictable than either NA or enzyme fasciotomy (EF). It is also a more durable treatment. NA and EF can be conceptualized as similar procedures--one uses a needle and the other an enzyme to weaken a cord sufficient to be able to rupture it and thus straighten a contracted joint. Both are less invasive and the hand is quick to recover. Both procedures are equally initially effective. CHH seems to offer greater durability. Today’s patients are often better educated and seek a specific type of treatment, in particular, effective nonoperative treatment. Pharmaceutical companies now market directly and effectively to patients, and this strategy and Internet use have already resulted in an increase in the number of patients searching for practitioners willing to administer and capable of administering collagenase treatment.
View details for DOI 10.1016/j.hc1.2013.08.016
View details for Web of Science ID 000329087000005
View details for PubMedID 24286739
-
Essential Hand Surgery Procedures for Mastery by Graduating Plastic Surgery Residents: A Survey of Program Directors
PLASTIC AND RECONSTRUCTIVE SURGERY
2013; 132 (6): 977E-984E
Abstract
This study was designed to establish the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. This framework can then be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach technical skills in hand surgery.Ten expert hand surgeons were surveyed regarding the essential hand surgery procedures that should be mastered by graduating plastic surgery residents. The top 10 procedures from this survey were then used to survey all 89 Accreditation Council for Graduate Medical Education-approved plastic surgery program directors.There was a 69 percent response rate to the program director survey (n = 61). The top nine hand surgery procedures included open carpal tunnel release, open A1 pulley release, digital nerve repair with microscope, closed reduction and percutaneous pinning of metacarpal fracture, excision of dorsal or volar ganglion, zone II flexor tendon repair with multistrand technique, incision and drainage of the flexor tendon sheath for flexor tenosynovitis, flexor tendon sheath steroid injection, and open cubital tunnel release.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method for accomplishing this task. There has been no consensus regarding which hand surgery procedures should be mastered by graduating plastic surgery residents. The authors have identified nine procedures that are overwhelmingly supported by plastic surgery program directors. These nine procedures can be used as a guideline for developing Objective Structured Assessment of Technical Skill to teach and document technical skills in hand surgery.
View details for DOI 10.1097/01.prs.0b013e3182a8066b
View details for Web of Science ID 000330465800009
View details for PubMedID 24281644
-
The fragmented proximal pole scaphoid nonunion treated with rib autograft: case series and review of the literature.
journal of hand surgery
2013; 38 (11): 2188-2192
Abstract
Nonunions of the proximal pole of the scaphoid are a challenge to treat given the limited vascular supply. This challenge is potentiated when the proximal pole is unsalvageable. When the proximal pole of the scaphoid is fragmented or otherwise unsalvageable, traditional reconstructive procedures such as vascularized or nonvascularized bone grafting are not possible. Salvage procedures such as proximal row carpectomy or scaphoid excision and partial wrist fusion would not be ideal in the case of an unsalvageable proximal pole scaphoid nonunion in the absence of radiocarpal arthrosis. In this relatively uncommon circumstance, we favor the use of rib osteochondral autograft reconstruction of the proximal pole of the scaphoid. We report 3 cases with greater than 2-years of follow-up evaluation and also review the literature.
View details for DOI 10.1016/j.jhsa.2013.08.093
View details for PubMedID 24055132
-
The Fragmented Proximal Pole Scaphoid Nonunion Treated With Rib Autograft: Case Series and Review of the Literature
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2013; 38A (11): 2188-2192
Abstract
Nonunions of the proximal pole of the scaphoid are a challenge to treat given the limited vascular supply. This challenge is potentiated when the proximal pole is unsalvageable. When the proximal pole of the scaphoid is fragmented or otherwise unsalvageable, traditional reconstructive procedures such as vascularized or nonvascularized bone grafting are not possible. Salvage procedures such as proximal row carpectomy or scaphoid excision and partial wrist fusion would not be ideal in the case of an unsalvageable proximal pole scaphoid nonunion in the absence of radiocarpal arthrosis. In this relatively uncommon circumstance, we favor the use of rib osteochondral autograft reconstruction of the proximal pole of the scaphoid. We report 3 cases with greater than 2-years of follow-up evaluation and also review the literature.
View details for DOI 10.1016/j.jhsa.2013.08.093
View details for Web of Science ID 000326553200015
-
Essential hand surgery procedures for mastery by graduating orthopedic surgery residents: a survey of program directors.
journal of hand surgery
2013; 38 (4): 760-765
Abstract
To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents.We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.This study addresses the future of orthopedic surgery education as it pertains to hand surgery.
View details for DOI 10.1016/j.jhsa.2012.12.035
View details for PubMedID 23433941
-
Essential Hand Surgery Procedures for Mastery by Graduating Orthopedic Surgery Residents: A Survey of Program Directors
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2013; 38A (4): 760-765
Abstract
To establish the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. This framework can then be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.A select group of 10 expert hand surgeons was surveyed regarding the essential hand surgery procedures that should be mastered by graduating orthopedic surgery residents. The top 10 procedures from this survey were then used to survey all 155 American Council of Graduate Medical Education-approved orthopedic surgery program directors regarding the essential procedures that should be mastered by graduating orthopedic surgery residents.We had a 39% response rate to the program director survey. The top 8 hand surgery procedures as determined by the orthopedic surgery program directors included open carpal tunnel release, open A1 pulley release, open reduction internal fixation of distal radius fracture, flexor tendon sheath steroid injection, excision of dorsal or volar ganglion, closed reduction and percutaneous pinning of metacarpal fracture, open cubital tunnel release, and incision and drainage of flexor tendon sheath for flexor tenosynovitis.Surgical educators need to develop objective methods to teach and document technical skill. The Objective Structured Assessment of Technical Skill is a valid method to accomplish this task. However, there has been no consensus regarding which hand surgery procedures should be mastered by graduating orthopedic surgery residents. We have identified 8 procedures that were overwhelmingly supported by orthopedic surgery program directors. These 8 procedures can be used as a guideline for developing an Objective Structured Assessment of Technical Skill to teach and document technical skill in hand surgery.This study addresses the future of orthopedic surgery education as it pertains to hand surgery.
View details for DOI 10.1016/j.jhsa.2012.12.035
View details for Web of Science ID 000317246100019
-
Making the case for case reports: open and shut, or case dismissed?
journal of hand surgery
2013; 38 (3): 433-434
View details for DOI 10.1016/j.jhsa.2012.12.014
View details for PubMedID 23428185
-
Capacity of Small Groups of Muscles to Accomplish Precision Grasping Tasks
IEEE. 2013: 6583–86
Abstract
An understanding of the capacity or ability of various muscle groups to generate endpoint forces that enable grasping tasks could provide a stronger biomechanical basis for the design of reconstructive surgery or rehabilitation for the treatment of the paralyzed or paretic hand. We quantified two-dimensional endpoint force distributions for every combination of the muscles of the index finger, in cadaveric specimens, to understand the capability of muscle groups to produce endpoint forces that accomplish three common types of grasps-tripod, tip and lateral pinch-characterized by a representative level of Coulomb friction. We found that muscle groups of 4 or fewer muscles were capable of generating endpoint forces that enabled performance of each of the grasping tasks examined. We also found that flexor muscles were crucial to accomplish tripod pinch; intrinsic muscles, tip pinch; and the dorsal interosseus muscle, lateral pinch. The results of this study provide a basis for decision making in the design of reconstructive surgeries and rehabilitation approaches that attempt to restore the ability to perform grasping tasks with small groups of muscles.
View details for Web of Science ID 000341702106242
View details for PubMedID 24111251
-
Advances in the Management of Dupuytren Disease Collagenase
HAND CLINICS
2012; 28 (4): 551-?
Abstract
Dupuytren disease (DD) is a benign, generally painless connective tissue disorder affecting the palmar fascia that leads to progressive hand contractures. Mediated by myofibroblasts, the disease most commonly begins as a nodule in the palm or finger, and can progress where pathologic cords form leading to progressive flexion deformity of the involved fingers. The palmar skin overlying the cords may become excessively calloused and contracted and involved joints may develop periarticular fibrosis. Although there is no cure, the sequellae of this affliction can be corrected. This article focuses on the role of collagen in DD and the development of a collagen-specific enzymatic treatment for DD contractures.
View details for DOI 10.1016/j.hcl.2012.08.003
View details for Web of Science ID 000311875800011
View details for PubMedID 23101605
-
The scaphotrapezial joint after partial trapeziectomy for trapeziometacarpal joint arthritis: long-term follow-up.
journal of hand surgery
2012; 37 (6): 1125-1129
Abstract
Partial trapeziectomy addresses trapeziometacarpal (TM) joint arthritis without the risk of destabilizing the scaphotrapezial (ST) joint. However, partial trapeziectomy has been criticized because of concern that ST joint arthritis will develop, requiring additional surgery. We hypothesized that partial trapeziectomy is a durable treatment for TM joint arthritis, even in patients with radiographically abnormal but asymptomatic ST joints.We evaluated 13 patients (16 thumbs) who underwent a partial trapeziectomy between 1995 and 2005. Assessment included grip strength, pinch strength, ST joint direct palpation, and ST joint stress testing. We classified standardized radiographs of the ST joint using a simple scoring system. Subjective data included the Disabilities of the Arm, Shoulder, and Hand questionnaire, a pain scale, and a satisfaction survey.The length of follow-up averaged 9 years (range, 5-13 y). No patient had pain at the ST joint with direct palpation or stress testing. Radiographs demonstrated a mean ST joint arthritis score of 1, indicating mild arthritic changes. Mean grip strength was 28 kg on the operated hand and 28 kg on the nonoperated hand. Mean pinch strength was 5 kg on the operated hand and 5 kg on the nonoperated hand. Scores on the pain scale averaged 6 (range, 0-100; 100 = worst). Average Disabilities of the Arm, Shoulder, and Hand score was 11 (range, 0-100; 100 = worst). Of 13 patients, 12 were very satisfied or extremely satisfied, and 1 was not satisfied.Partial trapeziectomy for TM joint arthritis provides long-lasting relief of symptoms in patients with radiographically abnormal but clinically insignificant ST joint degeneration. Satisfaction is equivalent to other published series. The radiographic appearance of the ST joint did not correlate with symptoms at this joint. Unless the patient has symptomatic ST joint arthritis, the ST joint may be retained.Therapeutic IV.
View details for DOI 10.1016/j.jhsa.2012.02.007
View details for PubMedID 22463926
-
The Scaphotrapezial Joint After Partial Trapeziectomy for Trapeziometacarpal Joint Arthritis: Long-term Follow-up
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2012; 37A (6): 1125-1129
Abstract
Partial trapeziectomy addresses trapeziometacarpal (TM) joint arthritis without the risk of destabilizing the scaphotrapezial (ST) joint. However, partial trapeziectomy has been criticized because of concern that ST joint arthritis will develop, requiring additional surgery. We hypothesized that partial trapeziectomy is a durable treatment for TM joint arthritis, even in patients with radiographically abnormal but asymptomatic ST joints.We evaluated 13 patients (16 thumbs) who underwent a partial trapeziectomy between 1995 and 2005. Assessment included grip strength, pinch strength, ST joint direct palpation, and ST joint stress testing. We classified standardized radiographs of the ST joint using a simple scoring system. Subjective data included the Disabilities of the Arm, Shoulder, and Hand questionnaire, a pain scale, and a satisfaction survey.The length of follow-up averaged 9 years (range, 5-13 y). No patient had pain at the ST joint with direct palpation or stress testing. Radiographs demonstrated a mean ST joint arthritis score of 1, indicating mild arthritic changes. Mean grip strength was 28 kg on the operated hand and 28 kg on the nonoperated hand. Mean pinch strength was 5 kg on the operated hand and 5 kg on the nonoperated hand. Scores on the pain scale averaged 6 (range, 0-100; 100 = worst). Average Disabilities of the Arm, Shoulder, and Hand score was 11 (range, 0-100; 100 = worst). Of 13 patients, 12 were very satisfied or extremely satisfied, and 1 was not satisfied.Partial trapeziectomy for TM joint arthritis provides long-lasting relief of symptoms in patients with radiographically abnormal but clinically insignificant ST joint degeneration. Satisfaction is equivalent to other published series. The radiographic appearance of the ST joint did not correlate with symptoms at this joint. Unless the patient has symptomatic ST joint arthritis, the ST joint may be retained.Therapeutic IV.
View details for DOI 10.1016/j.jhsa.2012.02.007
View details for Web of Science ID 000304977600002
-
Flexor tendon rupture after collagenase injection for Dupuytren contracture: case report.
journal of hand surgery
2011; 36 (8): 1323-1325
Abstract
Rupture of both flexor tendons after collagenase injection for Dupuytren contracture is a rare and problematic complication. We performed a 2-stage tendon reconstruction to treat this problem, with an acceptable result.
View details for DOI 10.1016/j.jhsa.2011.05.016
View details for PubMedID 21705158
-
Flexor Tendon Rupture After Collagenase Injection for Dupuytren Contracture: Case Report
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2011; 36A (8): 1323-1325
Abstract
Rupture of both flexor tendons after collagenase injection for Dupuytren contracture is a rare and problematic complication. We performed a 2-stage tendon reconstruction to treat this problem, with an acceptable result.
View details for DOI 10.1016/j.jhsa.2011.05.016
View details for Web of Science ID 000293669400011
-
The Treatment of Dupuytren Disease
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2011; 36A (5): 936-942
Abstract
The treatment of progressive Dupuytren contractures has historically been and continues to be largely surgical. Although a number of surgical interventions do exist, limited palmar fasciectomy continues to be the most common and widely accepted treatment option. Until recently, nonsurgical options were limited and clinically ineffective. However, the commercial availability and recent approval of collagenase clostridium histolyticum now provides practitioners with a nonsurgical approach to this disease. This article presents a comprehensive review of the surgical and nonsurgical treatments of Dupuytren disease, with a focus on collagenase.
View details for DOI 10.1016/j.jhsa.2011.03.002
View details for Web of Science ID 000290185700030
-
Biceps-to-triceps transfer technique.
journal of hand surgery
2011; 36 (4): 716-721
Abstract
Lack of voluntary active elbow extension inhibits many important functions in persons with tetraplegia. Biceps-to-triceps transfer can restore this function in selected patients. This article outlines the basic problem, indications and contraindications, surgical technique, and postoperative rehabilitation protocol for biceps-to-triceps transfer using the medial routing technique with suture anchoring of the biceps muscle tendon unit into the triceps aponeurosis and olecranon.
View details for DOI 10.1016/j.jhsa.2011.01.028
View details for PubMedID 21463733
-
Biceps-to-Triceps Transfer Technique
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2011; 36A (4): 716-721
Abstract
Lack of voluntary active elbow extension inhibits many important functions in persons with tetraplegia. Biceps-to-triceps transfer can restore this function in selected patients. This article outlines the basic problem, indications and contraindications, surgical technique, and postoperative rehabilitation protocol for biceps-to-triceps transfer using the medial routing technique with suture anchoring of the biceps muscle tendon unit into the triceps aponeurosis and olecranon.
View details for DOI 10.1016/j.jhsa.2011.01.028
View details for Web of Science ID 000289493300028
-
Comparison of wrist and elbow stabilization following pinch reconstruction in tetraplegia.
journal of hand surgery
2011; 36 (3): 480-485
Abstract
Individuals with spinal cord injuries resulting in tetraplegia may receive tendon transfer surgery to restore grasp and pinch function. These procedures often involve rerouting the brachioradialis (Br) and the extensor carpi radialis longus tendons volar to the flexion-extension axis of the wrist, leaving the extensor carpi radialis brevis (ECRB) muscle to provide wrist extension strength. The purpose of this study was to determine whether externally stabilizing the wrist after transfer procedures would improve the ability to activate the transferred Br and resulting pinch force, similar to the effect observed when the elbow is externally stabilized.We used a one-way repeated-measures study design to determine the effect of 3 support conditions on muscle activation and lateral pinch force magnitude in 8 individuals with tetraplegia and previous tendon transfer surgeries. Muscle activation was recorded from Br and ECRB with intramuscular electrodes and from biceps and triceps muscles with surface electrodes. We quantified pinch strength with a 6-axis force sensor and custom grip. We recorded measurements in 3 support conditions: with the arm self-stabilized, with elbow stabilization, and with elbow and wrist stabilization. Pairwise differences were tested using Wilcoxon signed-rank tests.Maximum effort pinch force magnitude and Br activation were significantly increased in both supported conditions compared with the self-supported trials. The addition of wrist stabilization had no significant effect compared with elbow stabilization alone.A strong ECRB has adequate strength to extend the wrist, even after multiple transfers that contribute an additional flexion moment from strong activation of donor muscles. Anatomical and functional differences between the wrist and elbow musculature are important determinants for self-stabilizing joints proximal to the tendon transfer. The ability to increase Br activation and resulting pinch force may be determined, in part, by the individual's ability to develop new coordination strategies.
View details for DOI 10.1016/j.jhsa.2010.11.006
View details for PubMedID 21277699
-
Comparison of Wrist and Elbow Stabilization Following Pinch Reconstruction in Tetraplegia
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2011; 36A (3): 480-485
Abstract
Individuals with spinal cord injuries resulting in tetraplegia may receive tendon transfer surgery to restore grasp and pinch function. These procedures often involve rerouting the brachioradialis (Br) and the extensor carpi radialis longus tendons volar to the flexion-extension axis of the wrist, leaving the extensor carpi radialis brevis (ECRB) muscle to provide wrist extension strength. The purpose of this study was to determine whether externally stabilizing the wrist after transfer procedures would improve the ability to activate the transferred Br and resulting pinch force, similar to the effect observed when the elbow is externally stabilized.We used a one-way repeated-measures study design to determine the effect of 3 support conditions on muscle activation and lateral pinch force magnitude in 8 individuals with tetraplegia and previous tendon transfer surgeries. Muscle activation was recorded from Br and ECRB with intramuscular electrodes and from biceps and triceps muscles with surface electrodes. We quantified pinch strength with a 6-axis force sensor and custom grip. We recorded measurements in 3 support conditions: with the arm self-stabilized, with elbow stabilization, and with elbow and wrist stabilization. Pairwise differences were tested using Wilcoxon signed-rank tests.Maximum effort pinch force magnitude and Br activation were significantly increased in both supported conditions compared with the self-supported trials. The addition of wrist stabilization had no significant effect compared with elbow stabilization alone.A strong ECRB has adequate strength to extend the wrist, even after multiple transfers that contribute an additional flexion moment from strong activation of donor muscles. Anatomical and functional differences between the wrist and elbow musculature are important determinants for self-stabilizing joints proximal to the tendon transfer. The ability to increase Br activation and resulting pinch force may be determined, in part, by the individual's ability to develop new coordination strategies.
View details for DOI 10.1016/j.jhsa.2010.11.006
View details for Web of Science ID 000288232200017
-
Collagenase clostridium histolyticum for Dupuytren's contracture
EXPERT OPINION ON BIOLOGICAL THERAPY
2010; 10 (9): 1395-1404
Abstract
Dupuytren's disease is a non-malignant, progressive disorder of the hands that can severely limit hand function and diminish overall quality of life. With global life expectancy increasing, the prevalence of this disease appears to be increasing amongst all ethnic groups. Treatment has traditionally remained surgical with few effective, nonsurgical options. However, with the introduction of collagenase clostridium histolyticum to treat Dupuytren's contractures, physicians and surgeons may be provided with a new, office-based, non-surgical option to treat this disease.The literature behind the use of collagenase to treat Dupuytren's disease; including its mechanism of action, safety, efficacy and clinical evidence behind its recent FDA approval.The latest information available on collagenase through a comprehensive review of PubMed and the websites of licensing organizations for medicinal products.Phase III, clinical trials on collagenase for treatment of Dupuytren's contractures have recently been completed. Meeting primary and secondary objectives, collagenase has obtained FDA approval for clinical use. Collagenase now provides a non-operative option for Dupuytren's disease. Although short-term results show that collagenase is safe and efficacious, long-term effects of repeat injections and contracture recurrence rates have yet to be examined.
View details for DOI 10.1517/14712598.2010.510509
View details for Web of Science ID 000281614500010
View details for PubMedID 20666587
-
Collagenase injection as nonsurgical treatment of Dupuytren's disease: 8-year follow-up.
journal of hand surgery
2010; 35 (4): 534-?
Abstract
Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytren's disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytren's contracture.Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytren's disease questionnaire, and had independent examination of joint motion by a single examiner.Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57 degrees in the MCP group. Average contracture was 9 degrees at 1 week, 11 degrees at 1 year, and 23 degrees at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45 degrees in the PIP group. Average contracture was 8 degrees at 1 weeks, 15 degrees at 1 year, and 60 degrees at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytren's disease.Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0 degrees -5 degrees of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high.
View details for DOI 10.1016/j.jhsa.2010.01.003
View details for PubMedID 20353858
-
Collagenase Injection as Nonsurgical Treatment of Dupuytren's Disease: 8-Year Follow-Up
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2010; 35A (4): 534-539
Abstract
Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytren's disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytren's contracture.Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytren's disease questionnaire, and had independent examination of joint motion by a single examiner.Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57 degrees in the MCP group. Average contracture was 9 degrees at 1 week, 11 degrees at 1 year, and 23 degrees at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45 degrees in the PIP group. Average contracture was 8 degrees at 1 weeks, 15 degrees at 1 year, and 60 degrees at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytren's disease.Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0 degrees -5 degrees of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high.
View details for DOI 10.1016/j.jhsa.2010.01.003
View details for Web of Science ID 000276604600002
-
Functional Restoration of the Upper Extremity in Tetraplegia
SPINAL CORD MEDICINE: PRINCIPLES AND PRACTICE, SECOND EDITION
2010: 642–58
View details for Web of Science ID 000276871800048
-
Injectable Collagenase Clostridium Histolyticum for Dupuytren's Contracture.
NEW ENGLAND JOURNAL OF MEDICINE
2009; 361 (10): 968-979
Abstract
Dupuytren's disease limits hand function, diminishes the quality of life, and may ultimately disable the hand. Surgery followed by hand therapy is standard treatment, but it is associated with serious potential complications. Injection of collagenase clostridium histolyticum, an office-based, nonsurgical option, may reduce joint contractures caused by Dupuytren's disease.We enrolled 308 patients with joint contractures of 20 degrees or more in this prospective, randomized, double-blind, placebo-controlled, multicenter trial. The primary metacarpophalangeal or proximal interphalangeal joints of these patients were randomly assigned to receive up to three injections of collagenase clostridium histolyticum (at a dose of 0.58 mg per injection) or placebo in the contracted collagen cord at 30-day intervals. One day after injection, the joints were manipulated. The primary end point was a reduction in contracture to 0 to 5 degrees of full extension 30 days after the last injection. Twenty-six secondary end points were evaluated, and data on adverse events were collected.Collagenase treatment significantly improved outcomes. More cords that were injected with collagenase than cords injected with placebo met the primary end point (64.0% vs. 6.8%, P < 0.001), as well as all secondary end points (P < or = 0.002). Overall, the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees, P < 0.001). The most commonly reported adverse events were localized swelling, pain, bruising, pruritus, and transient regional lymph-node enlargement and tenderness. Three treatment-related serious adverse events were reported: two tendon ruptures and one case of complex regional pain syndrome. No significant changes in flexion or grip strength, no systemic allergic reactions, and no nerve injuries were observed.Collagenase clostridium histolyticum significantly reduced contractures and improved the range of motion in joints affected by advanced Dupuytren's disease. (ClinicalTrials.gov number, NCT00528606.)
View details for Web of Science ID 000269480400006
View details for PubMedID 19726771
-
The management of the upper limb in incomplete lesions of the cervical spinal cord
HAND CLINICS
2008; 24 (2): 175-?
Abstract
Patients with incomplete cervical spinal cord injuries present unique challenges for the reconstructive surgeon. For example, their patterns of injury don't easily fit into the International Classification system familiar to surgeons; they don't lend themselves to a "recipe" approach to surgical decision-making; and they frequently have developed upper limb deformities that must be addressed before any consideration is made for functional surgery. Meanwhile, little has been published regarding surgery for these patients. This article summarizes issues related to evaluating and planning surgical procedures for the upper limb in incomplete lesions of the cervical spinal cord.
View details for DOI 10.1016/j.hcl.2008.01.003
View details for Web of Science ID 000256444800006
View details for PubMedID 18456124
-
Reconstruction of elbow extension
HAND CLINICS
2008; 24 (2): 185-?
Abstract
The loss of elbow extension power is particularly disabling for the nonambulatory patient. Reconstruction of elbow extension can be performed by a deltoid to triceps transfer or by a biceps to triceps transfer provides the most satisfying reconstruction for patients. Although the overall time for rehabilitation can be lengthy, the functional gain is substantial, predictable, and easily appreciated by the patient. Furthermore, the risks to residual preoperative function are practically nil.
View details for DOI 10.1016/j.hcl.2008.02.003
View details for Web of Science ID 000256444800007
View details for PubMedID 18456125
-
Use of intrinsic thumb muscles may help to improve lateral pinch function restored by tendon transfer
CLINICAL BIOMECHANICS
2008; 23 (4): 387-394
Abstract
For surgical reconstruction of lateral pinch following tetraplegia, the function of the paralyzed flexor pollicis longus is commonly restored. The purpose of this study was to investigate if one of the intrinsic muscles could generate a more suitably directed thumb-tip force during lateral pinch than that of flexor pollicis longus.Endpoint force resulting from 10 N applied to each thumb muscle was measured in eleven upper extremity cadaveric specimens. We utilized the Kruskal-Wallis test (alpha=0.05) to determine whether thumb-tip forces of intrinsic muscles were less directed toward the base of the thumb, i.e., proximally directed, than the thumb-tip force produced by flexor pollicis longus. Additionally, a biomechanical model was used to assess the effect of an increase in tendon force on intrinsic muscle endpoint forces.All of the intrinsic muscles produced thumb-tip force vectors, ranging from 127 degrees to 156 degrees , that were significantly (P<0.009) less proximally directed than that of flexor pollicis longus (66 degrees (46 degrees )). A biomechanical model predicted that intrinsic muscle thumb-tip forces would vary non-linearly with tendon force. A 2-fold increase in tendon force produced, on average, a 2.3-fold increase in force magnitude and an 8 degrees shift in force direction across all intrinsic muscles.This study suggests the possibility of using an intrinsic muscle, e.g., the flexor pollicis brevis (ulnar head), instead of flexor pollicis longus, to produce a more advantageously directed thumb-tip force during lateral pinch in the surgically-reconstructed tetraplegic thumb and thus potentially enhance function.
View details for DOI 10.1016/j.clinbiomech.2007.11.008
View details for Web of Science ID 000255797300002
View details for PubMedID 18180085
-
MOC-PS(SM) CME article: self-assessment and performance in practice: the carpal tunnel.
Plastic and reconstructive surgery
2008; 121 (4): 1-10
Abstract
After studying the article, the participant should be able to: 1. Conduct an appropriate history and physical examination for a patient suspected of having carpal tunnel syndrome. 2. Understand the role of provocative and other diagnostic tests pertinent to the diagnosis of carpal tunnel syndrome. 3. Understand the goals of the surgical treatment of carpal tunnel syndrome and how to obtain these. 4. Appreciate the common complications of carpal tunnel surgery and their management.The purpose of this article is to review important aspects of the history, physical examination, diagnosis, and management of carpal tunnel syndrome. Associated diseases, predisposing factors, and prognostic features are explored. The significance of diagnostic studies and the variety of anesthetic techniques with which to perform the surgery are reviewed. Evidence regarding the different surgical approaches, such as the open versus the endoscopic, is examined. Postoperative care issues such as therapy and splinting are examined. Finally, complications of carpal tunnel surgery and their management are outlined.
View details for DOI 10.1097/01.prs.0000305930.24851.26
View details for PubMedID 18379382
-
Dupuytren's Disease: History, Diagnosis, and Treatment
PLASTIC AND RECONSTRUCTIVE SURGERY
2007; 120 (3): 44E-54E
Abstract
After studying this article, the participant should be able to: 1. Describe the clinical features of the disease. 2. Describe the pathoanatomical structures in Dupuytren's disease. 3. Outline the various factors associated with Dupuytren's disease. 4. Describe the modalities for surgical and nonsurgical treatment of the condition. 5. Outline recent biomolecular knowledge about the basis of Dupuytren's disease.Dupuytren's disease is characterized by nodule formation and contracture of the palmar fascia, resulting in flexion deformity of the fingers and loss of hand function. The authors review the historical background, clinical features, and current therapy of Dupuytren's disease; preview treatment innovations; and present molecular data related to Dupuytren's disease. These new findings may improve screening for Dupuytren's disease and provide a better understanding of the disease's pathogenesis.
View details for DOI 10.1097/01.prs.0000278455.63546.03
View details for Web of Science ID 000207677600001
View details for PubMedID 17700106
-
Dupuytren's disease: history, diagnosis, and treatment
PLASTIC AND RECONSTRUCTIVE SURGERY
2007; 120 (3): 791-792
View details for DOI 10.1097/01.prs.0000278455.63546.03
View details for Web of Science ID 000248900100027
-
Late reconstruction for ulnar nerve palsy
HAND CLINICS
2007; 23 (3): 373-?
Abstract
Long term paralysis of the ulnar nerve is associated with an array of specific deficits and deformities. The numerous options for reconstruction are reviewed, as well as the specific patient considerations in selecting a strategy. An approach to late reconstruction for late ulnar nerve palsy is presented based upon the authors' experience and the available literature.
View details for DOI 10.1016/j.hcl.2007.05.003
View details for Web of Science ID 000249886700011
View details for PubMedID 17765589
-
Telerehabilitation using the Rutgers Master II glove following carpal tunnel release surgery: Proof-of-concept
IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING
2007; 15 (1): 43-49
Abstract
Carpal tunnel syndrome is caused by the compression of the median nerve as it transits the carpal tunnel, with an incidence of about 1% of the population. If surgery is needed, the treatment involves decompression of the median nerve followed sometimes by musculoskeletal outpatient rehabilitation. This paper presents a proof-of-concept pilot clinical trial in which the Rutgers Masters II haptic glove was tested on five subjects, who were two weeks post-hand surgery. Subjects trained for 13 sessions, 30 min per session, three sessions per week, and had no conventional outpatient therapy. Computerized measures of performance showed group effects in hand mechanical energy (1200% for the virtual ball squeezing and DigiKey exercises and 600% for the power putty exercise). Improvement in their hand function was also observed (a 38% reduction in virtual pegboard errors, and 70% fewer virtual hand ball errors). Clinical strength measures showed increases in grip (by up to 150%) and key pinch (up to 46%) strength in three of the subjects, while two subjects had decreased strength following the study. However, all five subjects improved in their tip pinch strength of their affected hand (between 20%-267%). When asked whether they would recommend the virtual reality exercises to others, four subjects very strongly agreed and one strongly agreed that they would.
View details for DOI 10.1109/TNSRE.2007.891393
View details for Web of Science ID 000245184200008
View details for PubMedID 17436875
-
Tumours of the hand
LANCET ONCOLOGY
2007; 8 (2): 157-166
Abstract
Hand tumours of soft-tissue and bony origin are frequently encountered, and clinicians must be able to distinguish typical benign entities from life-threatening or limb-threatening malignant diseases. In this Review, we present a diagnostic approach to hand tumours and describe selected cancers and their treatments. Soft-tissue tumours include ganglion cysts, giant-cell cancers and fibromas of the tendon sheath, epidermal inclusion cysts, lipomas, vascular lesions, peripheral-nerve tumours, skin cancers, and soft-tissue sarcomas. Bony tumours encompass enchondromas, aneurysmal bone cysts, osteoid osteomas, giant-cell lesions of bone, bone sarcomas, and metastases. We look at rates of recurrence and 5-year survival, and recommendations for adjunct chemotherapy and radiotherapy for malignant lesions.
View details for Web of Science ID 000244103100028
View details for PubMedID 17267330
-
Is microsurgical treatment of brachial plexus palsy better than conventional treatment?
HAND CLINICS
2007; 23 (1): 83-?
Abstract
There are some plexus injuries for which microneural plexus reconstruction provides the only good possibility of achieving useful limb function. These injuries include complete plexus palsies in the adult and baby, and incomplete upper plexus lesions in the adult. There are plexus injuries for which there is little to no role for microneurosurgery, such as the isolated C8, T1 injury in the adult (this is an extremely rare injury in babies). This article explores conventional versus microneurosurgical reconstruction for adult traumatic and birth-related brachial plexus palsies.
View details for DOI 10.1016/j.hcl.2007.01.006
View details for Web of Science ID 000246911500009
View details for PubMedID 17478255
-
Variability in surgical technique for brachioradialis tendon transfer. Evidence and implications.
journal of bone and joint surgery. American volume
2006; 88 (9): 2009-2016
Abstract
Transfer of the tendon of the brachioradialis muscle to the tendon of the flexor pollicis longus restores lateral pinch function after cervical spinal cord injury. However, the outcomes of the procedure are unpredictable, and the reasons for this are not understood. The purpose of this study was to document the degree of variability observed in the performance of this tendon transfer.The surgical technique used for the brachioradialis tendon transfer was assessed in two ways. First, the surgical attachment length of the brachioradialis was quantified, after transfer to the flexor pollicis longus, with use of intraoperative laser diffraction to measure muscle sarcomere length in eleven individuals (twelve limbs) with tetraplegia. Second, ten surgeons who regularly performed this procedure were surveyed regarding their tensioning preferences. Using a biomechanical model of the upper extremity, we investigated theoretically the effect of different surgical approaches on the active muscle-force-generating capacity of the transferred brachioradialis in functionally relevant elbow, wrist, and hand postures.The average sarcomere length (and standard deviation) of the transferred brachioradialis was 3.5 +/- 0.3 mum. That length was significantly correlated to the in situ sarcomere length (r(2) = 0.53, p < 0.05). Surgical tensioning preferences varied considerably; however, six of the ten surgeons positioned the patient's elbow between full extension (0 degrees of elbow flexion) and 50 degrees of flexion when selecting the attachment length, and six of the ten stated that their goal was to tension the transfer slightly tighter than its resting tension. The computer simulations suggested that a "tighter" brachioradialis transfer would produce its peak active force in an elbow position that is more flexed than the elbow position in which a "looser" transfer would produce its peak active force.This study provides evidence that experienced surgeons perform this tendon transfer differently from one another. Biomechanical simulations suggested that these differences could result in substantial variability in the active force that the transferred brachioradialis can produce in functionally relevant postures.The surgical attachment length and the position of the patient's limb at the time of tendon transfer are both controllable and measurable parameters. Understanding the relationship between surgical technique and postoperative muscle function may provide surgeons with more control of clinical outcomes.
View details for PubMedID 16951118
-
Variability in surgical technique for brachioradialis tendon transfer - Evidence and implications
JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME
2006; 88A (9): 2009-2016
Abstract
Transfer of the tendon of the brachioradialis muscle to the tendon of the flexor pollicis longus restores lateral pinch function after cervical spinal cord injury. However, the outcomes of the procedure are unpredictable, and the reasons for this are not understood. The purpose of this study was to document the degree of variability observed in the performance of this tendon transfer.The surgical technique used for the brachioradialis tendon transfer was assessed in two ways. First, the surgical attachment length of the brachioradialis was quantified, after transfer to the flexor pollicis longus, with use of intraoperative laser diffraction to measure muscle sarcomere length in eleven individuals (twelve limbs) with tetraplegia. Second, ten surgeons who regularly performed this procedure were surveyed regarding their tensioning preferences. Using a biomechanical model of the upper extremity, we investigated theoretically the effect of different surgical approaches on the active muscle-force-generating capacity of the transferred brachioradialis in functionally relevant elbow, wrist, and hand postures.The average sarcomere length (and standard deviation) of the transferred brachioradialis was 3.5 +/- 0.3 mum. That length was significantly correlated to the in situ sarcomere length (r(2) = 0.53, p < 0.05). Surgical tensioning preferences varied considerably; however, six of the ten surgeons positioned the patient's elbow between full extension (0 degrees of elbow flexion) and 50 degrees of flexion when selecting the attachment length, and six of the ten stated that their goal was to tension the transfer slightly tighter than its resting tension. The computer simulations suggested that a "tighter" brachioradialis transfer would produce its peak active force in an elbow position that is more flexed than the elbow position in which a "looser" transfer would produce its peak active force.This study provides evidence that experienced surgeons perform this tendon transfer differently from one another. Biomechanical simulations suggested that these differences could result in substantial variability in the active force that the transferred brachioradialis can produce in functionally relevant postures.The surgical attachment length and the position of the patient's limb at the time of tendon transfer are both controllable and measurable parameters. Understanding the relationship between surgical technique and postoperative muscle function may provide surgeons with more control of clinical outcomes.
View details for DOI 10.2106/JBJS.E.00973
View details for Web of Science ID 000240470900015
-
Activation of brachioradialis muscles transferred to restore lateral pinch in tetraplegia.
journal of hand surgery
2006; 31 (5): 747-753
Abstract
Surgical transfers of muscles are used to restore lateral pinch in tetraplegia; however, outcomes are variable. The purpose of this study was to compare activation of the brachioradialis (Br) after transfer to the flexor pollicis longus during maximum effort in its primary function (elbow flexion) with maximum effort in its postoperative function (lateral pinch) and to record Br activation during functional tasks.Fine-wire electrodes recorded activation of the Br in 11 arms with tetraplegia. Subjects produced maximum lateral pinch force with and without elbow stabilization and were classified according to elbow strength. The elbow was stabilized by supporting the arm and limiting elbow motion. A force sensor mounted on a custom grip recorded the pinch force. Electromyographic (EMG) signals recorded during lateral pinch were expressed as a percentage of the maximum voluntary contraction recorded during maximum-effort elbow flexion.The EMG activation was significantly lower during lateral pinch compared with resisted elbow flexion. The mean EMG during lateral pinch in the self-supported elbow condition was 34% of the maximum voluntary contraction; with the elbow stabilized the EMG increased to 55% of the maximum voluntary contraction. Postoperative pinch-force magnitude was 14 N with self-support and 20 N with the elbow stabilized. Subjects with weak elbow extension strength produced significantly lower pinch forces compared with subjects with strong elbow extension but had similar ability to activate the Br. The Br activation was higher when the pinch tasks were performed successfully.These findings suggest a reduced ability to activate the transferred muscle fully in lateral pinch function after surgery, even with the addition of elbow support. The Br activation is linked to successful performance of lateral pinch tasks. The subjects' inability to activate the transferred muscle fully may be affected by postoperative muscle re-education and contribute to postoperative weakness.
View details for PubMedID 16713837
-
Activation of brachioradialis muscles transferred to restore lateral pinch in tetraplegia
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2006; 31A (5): 747-753
Abstract
Surgical transfers of muscles are used to restore lateral pinch in tetraplegia; however, outcomes are variable. The purpose of this study was to compare activation of the brachioradialis (Br) after transfer to the flexor pollicis longus during maximum effort in its primary function (elbow flexion) with maximum effort in its postoperative function (lateral pinch) and to record Br activation during functional tasks.Fine-wire electrodes recorded activation of the Br in 11 arms with tetraplegia. Subjects produced maximum lateral pinch force with and without elbow stabilization and were classified according to elbow strength. The elbow was stabilized by supporting the arm and limiting elbow motion. A force sensor mounted on a custom grip recorded the pinch force. Electromyographic (EMG) signals recorded during lateral pinch were expressed as a percentage of the maximum voluntary contraction recorded during maximum-effort elbow flexion.The EMG activation was significantly lower during lateral pinch compared with resisted elbow flexion. The mean EMG during lateral pinch in the self-supported elbow condition was 34% of the maximum voluntary contraction; with the elbow stabilized the EMG increased to 55% of the maximum voluntary contraction. Postoperative pinch-force magnitude was 14 N with self-support and 20 N with the elbow stabilized. Subjects with weak elbow extension strength produced significantly lower pinch forces compared with subjects with strong elbow extension but had similar ability to activate the Br. The Br activation was higher when the pinch tasks were performed successfully.These findings suggest a reduced ability to activate the transferred muscle fully in lateral pinch function after surgery, even with the addition of elbow support. The Br activation is linked to successful performance of lateral pinch tasks. The subjects' inability to activate the transferred muscle fully may be affected by postoperative muscle re-education and contribute to postoperative weakness.
View details for DOI 10.1016/j.jhsa.2006.01.006
View details for Web of Science ID 000237881700010
-
Tele-rehabilitation using the Rutgers Master II glove following Carpal Tunnel Release surgery
2006 INTERNATIONAL WORKSHOP ON VIRTUAL REHABILITATION
2006: 88-93
View details for Web of Science ID 000242495200017
-
Biornechanical properties of the brachioradialis muscle: Implications for surgical tendon transfer
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2005; 30A (2): 273-282
Abstract
To understand the mechanical properties of the brachioradialis (BR) muscle and to use this information to simulate a BR-to-flexor pollicis longus (FPL) tendon transfer for restoration of lateral pinch.The BR mechanical properties were measured intraoperatively. Passive elastic properties were measured by elongating BR muscles at constant velocity while they were attached directly to a dual-mode servomotor. Sarcomere length was measured intraoperatively and in situ by laser diffraction with the elbow fully extended. Then both the mechanical and structural properties were programmed into a surgical simulator to test the hand surgeon's decision making when tensioning muscles in a simulated BR-to-FPL tendon transfer.Passive mechanical BR properties were highly nonlinear. Under slack conditions sarcomere length (mean +/- standard deviation) was 2.81 +/- 0.10 microm (n = 4), corresponding to an active force of 93% maximum. Sarcomere length of the BR measured in situ with the elbow fully extended and the forearm in neutral rotation was 3.90 +/- 0.27 microm (n = 8), corresponding to an active force of only 23% maximum. Surgeons, who tensioned the BR for transfer into the FPL using only tactile feedback from the surgical simulator, attached the muscle at a passive tension of 5.87 +/- 0.97 N, which corresponded to a sarcomere length of 3.84 microm and an active muscle force of 27% maximum. Passive BR tension when both tactile and visual information were provided to the surgeon was significantly lower (2.42 +/- 0.72 N), corresponding to a sarcomere length of 3.56 mum and a much higher active muscle force of 45% maximum.When these data were used to model pretransfer and posttransfer function dramatic differences in predicted function were obtained depending on the tensioning protocol chosen. This emphasizes the point that the decision-making process used during muscle tensioning has a profound effect on the functional outcome of the transfer.
View details for DOI 10.1016/j.jhsa.2004.10.003
View details for Web of Science ID 000227824700008
-
The effect of percutaneous pin fixation of the interphalangeal joint on the thumb-tip force produced by the flexor pollicis longus: A Cadaver study
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2004; 29A (6): 1056-1062
Abstract
Interphalangeal joint stabilization often is performed concomitantly with tendon transfers that restore key pinch (lateral pinch) to the paralyzed thumb. The goal of this study was to measure the effect of interphalangeal joint stabilization via percutaneous pin fixation on the thumb-tip force produced by the flexor pollicis longus (FPL).We applied 10 N of force to the tendon of the FPL in 7 cadaveric specimens and measured the resulting thumb-tip force in the intact thumb and after stabilization of the interphalangeal joint.The nominal thumb-tip force was approximately 6 times less than the applied force and was directed primarily in the thumb's plane of flexion-extension at an oblique angle of 44 degrees relative to the palmar direction (the direction that is perpendicular to the thumb tip in the plane). Joint stabilization increased significantly the nominal force and oriented the force more toward the palmar direction (ie, decreased the obliqueness of the force).After paralysis and a tendon transfer to the paralyzed FPL the FPL is often the only muscle actuating the thumb. We conclude that the oblique nominal force direction is prone to cause the thumb to slip during pinch. Joint stabilization, however, has the capacity to reduce the tendency for slippage because it rotates the force toward the palmar direction.
View details for DOI 10.1016/j.jhsa.2004.07.005
View details for Web of Science ID 000225518200011
-
Congenital brachial plexus exploration.
Techniques in hand & upper extremity surgery
2004; 8 (2): 58-69
Abstract
Stanford's experience in the management of obstetrical brachial plexus palsy dates from 1983. A formal clinic service began in 1992. The tenets of management include early evaluations, a dependency on sequential evolution for decision-making, and very early neural surgery for babies with abnormal hands. We watch babies with normal hands for a longer time before advising surgery. At exploration, common patterns of injury are observed. Intraoperative evoked potentials are used to make surgical decisions. Reconstructive goals for upper plexus injuries include shoulder and elbow control. The paramount goal for babies with global palsies is hand function. Therapy throughout the child's growth years is vital. Sequelae, particularly shoulder contractures, require early surgical intervention. Secondary reconstructive procedures are typically beneficial in improving function. Since 1992, over 400 children have been examined, 62 have had neural reconstruction, and 102 have undergone secondary procedures. Surgery has been remarkably complication free. All children having neural reconstruction except 2 have been benefited.
View details for PubMedID 16518116
-
Identification of key pinch forces required to complete functional tasks
JOURNAL OF REHABILITATION RESEARCH AND DEVELOPMENT
2004; 41 (2): 215-223
Abstract
Reconstructive hand surgeries restore key pinch to individuals with pinch force deficits caused by tetraplegia. Data that define the magnitudes of force necessary to complete functional key pinch tasks are limited. This study aims to establish target pinch forces for completing selected tasks that represent a range of useful functional activities. A robot arm instrumented with a force sensor completed the tasks and simultaneously measured the forces applied to the task objects. Lateral pinch force requirements were calculated from these measured object forces. Pinch force requirements ranged from 1.4 N to push a button on a remote to 31.4 N to insert a plug into an outlet. Of the tasks studied, 9 of 12 required less than 10.5 N. These pinch force requirements, when compared to pinch forces produced by 14 individuals with spinal cord injuries (with and without surgical reconstruction of pinch), accurately predicted success or failure in 81% of subject trials. The prediction errors indicate a need to measure other factors such as pinch opening, force location, force direction, and proximal joint control.
View details for Web of Science ID 000221807600014
View details for PubMedID 15558375
-
Invited discussion: Proximal radial compression neuropathy
ANNALS OF PLASTIC SURGERY
2004; 52 (2): 181–83
View details for DOI 10.1097/01.sap.0000095661.75866.38
View details for Web of Science ID 000188595600013
-
Biomechanics of the Steindler flexorplasty surgery: a computer simulation study.
journal of hand surgery
2003; 28 (6): 979-986
Abstract
Our goal was to investigate the capacity of a Steindler flexorplasty to restore elbow flexion to persons with C5-C6 brachial plexus palsy. In this procedure the origin of the flexor-pronator mass is moved proximally onto the humeral shaft. We examined how the choice of the proximal attachment site for the flexor-pronator mass affects elbow flexion restoration, especially considering possible side effects including limited wrist and forearm motion owing to passive restraint from stretched muscles.A computer model of the upper extremity was used to simulate the biomechanical consequences of various surgical alterations. Unimpaired, preoperative, and postoperative conditions were simulated. Seven possible transfer locations were used to investigate the effects of choice of transfer location.Each transfer site produced a large increase in elbow flexion strength. Transfer to more proximal attachment sites also produced large increases in passive resistance to wrist extension and forearm supination.To reduce detrimental side effects while achieving clinical goals our theoretical analysis suggests a transfer to the distal limit of the traditional transfer region.
View details for PubMedID 14642514
-
Biomechanics of the Steindler flexorplasty surgery: A computer simulation study
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2003; 28A (6): 979-986
Abstract
Our goal was to investigate the capacity of a Steindler flexorplasty to restore elbow flexion to persons with C5-C6 brachial plexus palsy. In this procedure the origin of the flexor-pronator mass is moved proximally onto the humeral shaft. We examined how the choice of the proximal attachment site for the flexor-pronator mass affects elbow flexion restoration, especially considering possible side effects including limited wrist and forearm motion owing to passive restraint from stretched muscles.A computer model of the upper extremity was used to simulate the biomechanical consequences of various surgical alterations. Unimpaired, preoperative, and postoperative conditions were simulated. Seven possible transfer locations were used to investigate the effects of choice of transfer location.Each transfer site produced a large increase in elbow flexion strength. Transfer to more proximal attachment sites also produced large increases in passive resistance to wrist extension and forearm supination.To reduce detrimental side effects while achieving clinical goals our theoretical analysis suggests a transfer to the distal limit of the traditional transfer region.
View details for DOI 10.1016/S0363-5023(03)00484-2
View details for Web of Science ID 000186710500014
-
Three-dimensional hyaluronic acid grafts promote healing and reduce scar formation in skin incision wounds.
Journal of biomedical materials research. Part B, Applied biomaterials
2003; 67 (1): 586-592
Abstract
Hyaluronic acid (HA) has been found to play important roles in tissue regeneration and wound-healing processes. Fetal tissue with a high concentration of HA heals rapidly without scarring. The present study employed HA formed into three-dimensional strands with or without keratinocytes to treat full-thickness skin incision wounds in rats. Wound closure rates of HA strand grafts both with and without keratinocytes were substantially enhanced. The closure times of both HA grafts were less than 1 day (average 16 h), about 1/7 that of the contralateral control incisions (114 h, p <.01). Average wound areas after 10 days were HA-only graft: 0.151 mm2 +/- 0.035; HA + cell grafts: 0.143 mm2 +/- 0.036 and controls: 14.434 mm2 +/- 1.175, experimental areas were 1% of the controls (p < 0.01). Transforming growth factor (TGF) beta1 measured by immunostaining was remarkably reduced in HA-treated wounds compared to the controls. In conclusion, HA grafts appeared to produce a fetal-like environment with reduced TGF-beta1, which is known to be elevated in incipient scars. The HA strands with or without cultured cells may potentially improve clinical wound healing as well as reduce scar formation.
View details for PubMedID 14528455
-
Three-dimensional hyaluronic acid grafts promote healing and reduce scar formation in skin incision wounds
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART B-APPLIED BIOMATERIALS
2003; 67B (1): 586-592
Abstract
Hyaluronic acid (HA) has been found to play important roles in tissue regeneration and wound-healing processes. Fetal tissue with a high concentration of HA heals rapidly without scarring. The present study employed HA formed into three-dimensional strands with or without keratinocytes to treat full-thickness skin incision wounds in rats. Wound closure rates of HA strand grafts both with and without keratinocytes were substantially enhanced. The closure times of both HA grafts were less than 1 day (average 16 h), about 1/7 that of the contralateral control incisions (114 h, p <.01). Average wound areas after 10 days were HA-only graft: 0.151 mm2 +/- 0.035; HA + cell grafts: 0.143 mm2 +/- 0.036 and controls: 14.434 mm2 +/- 1.175, experimental areas were 1% of the controls (p < 0.01). Transforming growth factor (TGF) beta1 measured by immunostaining was remarkably reduced in HA-treated wounds compared to the controls. In conclusion, HA grafts appeared to produce a fetal-like environment with reduced TGF-beta1, which is known to be elevated in incipient scars. The HA strands with or without cultured cells may potentially improve clinical wound healing as well as reduce scar formation.
View details for DOI 10.1002/jbm.b.20001
View details for Web of Science ID 000185750200002
-
Injury to the dorsal sensory branch of the ulnar nerve in the arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: a cadaver study.
journal of hand surgery
2002; 27 (5): 840-844
Abstract
This anatomic study of the commonly described inside-out Tuohy needle technique was performed to better define the course of needle passage relative to the anatomic structures in this region including the dorsal sensory branch of the ulnar nerve (DBUN) and extensor carpi ulnaris (ECU) tendon. Ten fresh-frozen cadaver specimens had arthroscopic-guided passage of a Tuohy needle through the triangular fibrocartilage (TFC). Dissection of the ulnar side of the wrist was performed and various measurements were recorded. The average minimum distance between suture A (the suture closest to the nerve) and the DBUN was 1.9 mm. The average minimum distance between suture B and the DBUN was 2.7 mm. The distance between the 2 sutures at the level of the capsule averaged 6.2 mm. The distance between the DBUN and the ECU averaged 7.2 mm. In 5 of 10 specimens the sutures exited on opposite sides of the DBUN. The DBUN is variable in its course but in every case it passes in close proximity to the sutures that exit the ulnar side of the wrist in arthroscopic repair of ulnar-sided TFC tears.
View details for PubMedID 12239674
-
Injury to the dorsal sensory branch of the ulnar nerve in the Arthroscopic repair of ulnar-sided triangular fibrocartilage tears using an inside-out technique: A cadaver study
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2002; 27A (5): 840-844
Abstract
This anatomic study of the commonly described inside-out Tuohy needle technique was performed to better define the course of needle passage relative to the anatomic structures in this region including the dorsal sensory branch of the ulnar nerve (DBUN) and extensor carpi ulnaris (ECU) tendon. Ten fresh-frozen cadaver specimens had arthroscopic-guided passage of a Tuohy needle through the triangular fibrocartilage (TFC). Dissection of the ulnar side of the wrist was performed and various measurements were recorded. The average minimum distance between suture A (the suture closest to the nerve) and the DBUN was 1.9 mm. The average minimum distance between suture B and the DBUN was 2.7 mm. The distance between the 2 sutures at the level of the capsule averaged 6.2 mm. The distance between the DBUN and the ECU averaged 7.2 mm. In 5 of 10 specimens the sutures exited on opposite sides of the DBUN. The DBUN is variable in its course but in every case it passes in close proximity to the sutures that exit the ulnar side of the wrist in arthroscopic repair of ulnar-sided TFC tears.
View details for DOI 10.1053/jhsu.2002.34370
View details for Web of Science ID 000178152400012
-
Releasing the A3 pulley and leaving flexor superficialis intact increases pinch force following the Zancolli lasso procedures to prevent claw deformity in the intrinsic palsied finger
JOURNAL OF ORTHOPAEDIC RESEARCH
2002; 20 (5): 902-909
Abstract
Objective estimates of fingertip force magnitude following surgery to prevent digital metacarpophalangeal (MCP) hyperextension (clawing) in cases of paralysis of the hand's intrinsic muscles will assist clinicians in setting realistic expectations for post-operative pinch strength. We used a cadaveric/optimization approach to predict and confirm the maximal biomechanically possible fingertip force in the intrinsic palsied hand before and after two popular tendon transfer methods to the volar plate of the MCP joint. Both surgeries were also evaluated after release of the A3 pulley-a modification predicted by our published computer model of the forefinger to increase fingertip force magnitude. We predicted maximal static fingertip force by mounting eight fresh cadaveric hands on a frame, placing their forefinger in a functional posture (neutral abduction, 45 degrees of flexion at the MCP and proximal interphalangeal joints, and 10 degrees at the distal interphalangeal joint) and pinning the distal phalanx to a 3D dynamometer. We pulled on individual tendons with tensions up to 25% of maximal isometric force of their associated muscle and measured fingertip force and torque output. Using these measurements, we predicted the optimal combination of tendon tensions that maximized palmar force (analogous to pinch force, directed perpendicularly from the midpoint of the distal phalanx, and in the plane of finger flexion-extension) for four cases: (i) the non-paretic case (all muscles available), (ii) intrinsic palsied hand (no intrinsic muscles functioning), (iii) transfer of flexor superficialis tendon to the volar plate of the MCP (Zancolli lasso) in the intrinsic palsied hand, and (iv) leaving flexor superficialis intact and transferring a tendon of comparable strength to the volar plate of the MCP in the intrinsic palsied hand. Lastly, we applied these optimal combinations of tension to the cadaveric tendons and measured fingertip output. With the A3 pulley intact, the maximal palmar force in cases (ii)-(iv) averaged 48 +/- 23% SD (non-paretic = 100%; case (iv) (61 +/- 25%) > cases (ii) and (iii) (43 +/- 23% and 39 +/- 19%, respectively), p < 0.05). Releasing the A3 pulley significantly increased the average palmar force in cases (ii)-(iv) (73 +/- 42%, p < 0.05), with no significant differences among them. Thus, releasing the A3 pulley may improve palmar force magnitude when it is necessary to transfer the digit's own flexor superficialis tendon to the volar plate of the MCP to prevent clawing in the intrinsic palsied hand.
View details for Web of Science ID 000178383400003
View details for PubMedID 12382952
-
Collagen as a clinical target: Nonoperative treatment of Dupuytren's disease
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2002; 27A (5): 788-798
Abstract
The cellular events leading to abnormal synthesis of collagen are important to our understanding of pathologic processes leading to impaired joint function. The contracture of Dupuytren's disease is a notable example. In a series of controlled phase-2 clinical trials, excessive collagen deposition in Dupuytren's disease has been targeted by a unique nonoperative method using enzyme (Clostridial collagenase) injection therapy to lyse and rupture finger cords causing metacarpophalangeal and/or proximal interphalangeal joint contractures. Forty-nine patients were treated in a random, placebo-controlled trial of one dose of collagenase versus placebo at one center. Subsequently 80 patients were treated in a random, placebo-controlled, dose-response study of collagenase at 2 test centers. The results of these studies indicate that nonoperative collagenase injection therapy for Dupuytren's disease is both a safe and effective method of treating this disorder in the majority of patients as an alternative to surgical fasciectomy. Phase-3 efficacy trials are now being planned to further develop and test this method under Food and Drug Administration regulatory guidelines. The findings of our study may lead to simpler and less invasive nonoperative treatments of joint limitation in which collagen plays a major pathologic role.
View details for DOI 10.1053/jhsu.2002.35299
View details for Web of Science ID 000178152400004
-
Surgical strategy: matching the patient with the procedure
HAND CLINICS
2002; 18 (3): 503-?
Abstract
The general indications, timing, and choice of procedure can be determined by asking and answering the following questions appropriately: 1. Has the patient achieved neurologic, emotional, and social stability? 2. What is the patient's current level of motor and sensory resources and function? The number and strength of muscles remaining under good voluntary control are the most important variables. 3. Are the patient's expectations realistic? 4. Does the patient possess the necessary intelligence and motivation? Some procedures, such as arthrodesis of a specific joint, require little motivation to succeed; however, a complex set of muscle-tendon transfers requires a great deal of motor reeducation for the patient to achieve an optimal result. 5. Does the patient have the necessary time to invest in achieving a good result? The patient must be able to set aside the time necessary for postoperative immobilization in a cast or splint and for therapy and reeducation. 6. Are the necessary support services and personnel available and committed? 7. Have all preoperative obstacles to success been considered and has a plan developed to overcome any remaining obstacles? 8. Does the patient understand the potential complications and benefits? 9. Can the patient and professional team tolerate a complication, failure, or suboptimal result? Both the medical staff and the patient must be prepared for complications that may lead to a suboptimal outcome or frank failure. 10. Are the patient's current health and well-being ideal? 11. Is the surgical plan consistent with the patient's physical resources, goals, and expectations? 12. Does an alternate plan exist? 13. Does the surgeon understand the scope of the complications and how to salvage an acceptable result should a complication occur?
View details for Web of Science ID 000179737000014
View details for PubMedID 12474600
-
Reconstruction of the hand in Apert syndrome: A simplified approach
PLASTIC AND RECONSTRUCTIVE SURGERY
2002; 109 (2): 465-470
Abstract
Children born with Apert acrocephalosyndactyly pose great challenges to the pediatric hand surgeon. Reconstructive dilemmas consist of shortened, deviated phalanges and extensive skin deficits following syndactyly release. We present a 10-year review of patients with Apert acrocephalosyndactyly who were treated with a simplified surgical approach. Between 1986 and 1996, 10 patients with Apert syndrome underwent reconstructive surgery of their hands. The overall strategy involved early bilateral separation of syndactylous border digits at 1 year of age, followed by sequential unilateral middle syndactyly mass separation with thumb osteotomy and bone grafting as needed. In these 10 patients, a total of 53 web spaces were released, 49 of which involved osteotomies for complex syndactyly. Only local flaps and full-thickness skin grafts from the groin were used in all cases to achieve soft-tissue coverage. To date, seven of the 53 web spaces have needed revision (revision rate, 13 percent). Eleven thumb osteotomies (nine opening wedge and two closing wedge) were performed. Bone grafts from the proximal ulna or from other digits were used in all cases. To date, none of these thumb osteotomies have needed revision. This early, simplified approach to the complex hand anomalies of Apert acrocephalosyndactyly has been successful in achieving low revision rates and excellent functional outcomes as measured by gross grasp and pinch and by patient and parent satisfaction.
View details for PubMedID 11818821
-
Gene expression of transforming growth factor beta isoforms in interposition nerve grafting.
journal of hand surgery
2001; 26 (6): 1082-1087
Abstract
Scar production and neuroma formation at nerve graft coaptation sites may limit axonal regeneration and impair functional outcome. Transforming growth factor beta (TGF-beta) is a family of growth factors that is involved in scar formation, wound healing, and nerve regeneration. Fifteen adult Sprague-Dawley rats underwent autogenous nerve grafting. The nerve grafts were analyzed by in situ hybridization to determine the temporal and spatial expression of TGF-beta1 and TGF-beta3 messenger RNA (mRNA). The grafted nerves showed increased expression of TGF-beta1 and TGF-beta3 mRNA in the nerve and the surrounding connective tissue during the first postoperative week. These data suggest that modulation of TGF-beta levels in the first postoperative week may be effective in helping to control scar formation and improve nerve regeneration.
View details for PubMedID 11721255
-
Gene expression of transforming growth factor beta isoforms in interposition nerve grafting
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2001; 26A (6): 1082-1087
Abstract
Scar production and neuroma formation at nerve graft coaptation sites may limit axonal regeneration and impair functional outcome. Transforming growth factor beta (TGF-beta) is a family of growth factors that is involved in scar formation, wound healing, and nerve regeneration. Fifteen adult Sprague-Dawley rats underwent autogenous nerve grafting. The nerve grafts were analyzed by in situ hybridization to determine the temporal and spatial expression of TGF-beta1 and TGF-beta3 messenger RNA (mRNA). The grafted nerves showed increased expression of TGF-beta1 and TGF-beta3 mRNA in the nerve and the surrounding connective tissue during the first postoperative week. These data suggest that modulation of TGF-beta levels in the first postoperative week may be effective in helping to control scar formation and improve nerve regeneration.
View details for Web of Science ID 000172412500014
-
Efficacy of an implanted neuroprosthesis for restoring hand grasp in tetraplegia: A multicenter study
ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
2001; 82 (10): 1380-1388
Abstract
To evaluate an implanted neuroprosthesis that allows tetraplegic users to control grasp and release in 1 hand.Multicenter cohort trial with at least 3 years of follow-up. Function for each participant was compared before and after implantation, and with and without the neuroprosthesis activated.Tertiary spinal cord injury (SCI) care centers, 8 in the United States, 1 in the United Kingdom, and 1 in Australia.Fifty-one tetraplegic adults with C5 or C6 SCIs.An implanted neuroprosthetic system, in which electric stimulation of the grasping muscles of 1 arm are controlled by using contralateral shoulder movements, and concurrent tendon transfer surgery. Assessed participants' ability to grasp, move, and release standardized objects; degree of assistance required to perform activities of daily living (ADLs), device usage; and user satisfaction.Pinch force; grasp and release tests; ADL abilities test and ADL assessment test; and user satisfaction survey.Pinch force was significantly greater with the neuroprosthesis in all available 50 participants, and grasp-release abilities were improved in 49. All tested participants (49/49) were more independent in performing ADLs with the neuroprosthesis than they were without it. Home use of the device for regular function and exercise was reported by over 90% of the participants, and satisfaction with the neuroprosthesis was high.The grasping ability provided by the neuroprosthesis is substantial and lasting. The neuroprosthesis is safe, well accepted by users, and offers improved independence for a population without comparable alternatives.
View details for DOI 10.1053/apmr.2001.25910
View details for Web of Science ID 000171410800006
View details for PubMedID 11588741
-
Surgeon-patient barrier efficiency monitored with an electronic device in three surgical settings
WORLD JOURNAL OF SURGERY
2001; 25 (9): 1101-1108
Abstract
Blood-borne viral pathogens are an occupational threat to health care workers (HCWs), particularly those in the operating room. A major risk is posed by accidental penetrating injury, but skin contamination with body fluids from an infected patient, with prolonged intimate cutaneous contact, is a frequent occurrence during surgery, carrying further risk of transdermal infection. We have monitored barrier failure in three surgical settings (microsurgery, orthopedic surgery, general surgery) by means of an electronic surveillance device. A total of 111 surgical procedures were monitored: 67 microsurgeries, 22 orthopedic surgeries, and 22 general surgeries. Of the 278 electronic alarms signaling barrier failure, 44 (15.8%) were associated with glove perforation, 39 of which (88.6%) were not perceived by the operator. In 16 of those, the skin was visibly stained with the patient's blood. Altogether, 76 of the alarms (27.3%) were consequent to contacts caused by soaked gowns/sleeves, and 121 (43.5%) were attributed to hydration of latex porosities; 37 alarms (13.4%) were unexplained false positives. On only one occasion did a surgeon observe blood stains on his hands without a previous alarm; this event was classified as a device failure due to incorrect wiring. Double-gloving offered satisfactory protection against skin contamination during microsurgery but not during orthopedic surgery. The data presented here indicate that electronic monitoring of the surgical barrier enables prompt detection of barrier failure, especially at the level of the gloves, thereby limiting skin contamination with patients' body fluids during surgery.
View details for Web of Science ID 000170934500001
View details for PubMedID 11571942
-
Activation patterns of the thumb muscles during stable and unstable pinch tasks
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
2001; 26A (4): 698-705
Abstract
The ability to direct forces between the thumb and fingers is important to secure objects in the hand. We compared the coordination of thumb musculature in key and opposition pinch postures between stable and unstable tasks. The unstable task (producing thumb-tip force wearing a beaded thimble) required well-directed forces; the stable task (producing thumb-tip force against a pinch meter) did not. Fine-wire electromyography of thumb muscles and thumb-tip force magnitudes were recorded. We found no statistical differences in thumb-tip force between postures or stable versus unstable tasks, indicating that the highest magnitudes of force can be accurately directed. Abductor pollicis brevis and extensor pollicis longus were significantly more activated in the unstable tasks, suggesting their importance in directing thumb-tip force. Understanding how pinch forces are directed might influence the choice of muscle-tendon transfers performed to restore function to the severely paralyzed thumb. We introduce a device to quantify the ability to control pinch force magnitude and direction simultaneously.
View details for DOI 10.1053/jhsu.2001.26188
View details for Web of Science ID 000169983400019
-
Tissue engineering for reconstruction of the thumb.
NEW ENGLAND JOURNAL OF MEDICINE
2001; 344 (20): 1547–48
View details for DOI 10.1056/NEJM200105173442011
View details for Web of Science ID 000168677200011
View details for PubMedID 11357161
-
Successful hand transplantation - One-year follow-up.
NEW ENGLAND JOURNAL OF MEDICINE
2001; 344 (1): 65
View details for Web of Science ID 000166160400020
View details for PubMedID 11187117
-
Improvement of schwann cell attachment and proliferation on modified hyaluronic acid strands by polylysine
TISSUE ENGINEERING
2000; 6 (6): 585-593
Abstract
Hyaluronic acid (HyA) has the intrinsic ability to promote cell proliferation and reduce scar formation. However, the clinical use of HyA has so far been limited because of its water solubility and nonadhesive characteristics. Increasing interest in HyA as a clinically useful biomaterial has prompted our study of altering HyA's physical properties to render it a potential component of nerve grafts. In this study, strands of HyA were cross-linked by glutaraldehyde (Glut), coated with polylysine, and then inoculated with Schwann cells (SCs). Results in vivo and in vitro demonstrated that cross-linked HyA strands were water insoluble and thus less biodegradable. Poly-D-lysine-resurfaced strands showed significant SC attachment of 350-400 cells/mm(2), compared to uncoated controls (0-10 cells/mm(2), p < 0.01). Fibroblast control groups showed an attachment of 40-100 cells/mm(2) on coated strands. Immunostaining for proliferating cells showed SCs as and fibroblasts as +. Cells neither adhered to nor proliferated on the modified HyA strands that were not resurfaced. The results suggest that polylysine promotes SC attachment and proliferation to glutaraldehyde-cross-linked HyA strands, the product being a three-dimensional composite with low solubility that may have potential application in nerve grafts.
View details for Web of Science ID 000165511500001
View details for PubMedID 11103080
-
Quantification of fingertip force reduction in the forefinger following simulated paralysis of extensor and intrinsic muscles
JOURNAL OF BIOMECHANICS
2000; 33 (12): 1601-1609
Abstract
Objective estimates of fingertip force reduction following peripheral nerve injuries would assist clinicians in setting realistic expectations for rehabilitating strength of grasp. We quantified the reduction in fingertip force that can be biomechanically attributed to paralysis of the groups of muscles associated with low radial and ulnar palsies. We mounted 11 fresh cadaveric hands (5 right, 6 left) on a frame, placed their forefingers in a functional posture (neutral abduction, 45 degrees of flexion at the metacarpophalangeal and proximal interphalangeal joints, and 10 degrees at the distal interphalangeal joint) and pinned the distal phalanx to a six-axis dynamometer. We pulled on individual tendons with tensions up to 25% of maximal isometric force of their associated muscle and measured fingertip force and torque output. Based on these measurements, we predicted the optimal combination of tendon tensions that maximized palmar force (analogous to tip pinch force, directed perpendicularly from the midpoint of the distal phalanx, in the plane of finger flexion-extension) for three cases: non-paretic (all muscles of forefinger available), low radial palsy (extrinsic extensor muscles unavailable) and low ulnar palsy (intrinsic muscles unavailable). We then applied these combinations of tension to the cadaveric tendons and measured fingertip output. Measured palmar forces were within 2% and 5 degrees of the predicted magnitude and direction, respectively, suggesting tendon tensions superimpose linearly in spite of the complexity of the extensor mechanism. Maximal palmar forces for ulnar and radial palsies were 43 and 85% of non-paretic magnitude, respectively (p<0.05). Thus, the reduction in tip pinch strength seen clinically in low radial palsy may be partly due to loss of the biomechanical contribution of forefinger extrinsic extensor muscles to palmar force. Fingertip forces in low ulnar palsy were 9 degrees further from the desired palmar direction than the non-paretic or low radial palsy cases (p<0.05).
View details for Web of Science ID 000165360800009
View details for PubMedID 11006384
-
The protective efficacy of surgical latex gloves against the risk of skin contamination: how well are the operators protected?
JOURNAL OF MATERIALS SCIENCE-MATERIALS IN MEDICINE
2000; 11 (12): 825-832
Abstract
Latex gloves are used by surgical staff to avoid exposure to patient body fluids, thus reducing the risk of contracting bloodborne viral diseases, such as hepatitis C and HIV. We studied the efficacy of the surgical barrier provided by latex gloves, before and after use in the operating theater. The electrical conductivity, insulation and mechanical resistance of glove latex were investigated, using routine supplies of surgical gloves. Latex structure was assessed by scanning electron microscopy and by mercury intrusion porosimetry. Latex is subject to hydration, a phenomenon associated in the laboratory with the loss of its electrical insulation properties. Such glove latex properties were found to be highly variable, with latex hydration times varying between 2 and more than 30 min. Rapidly hydrating gloves showed increased permeability to methylene blue, associated with higher levels of porosity. Thirty min of surgical use was associated with measurable hydration of glove latex and a statistically significant loss of electrical and mechanical resistance, with rupture load decreasing by 24%. Electronic control of the insulation properties of gloves during surgery permits early detection of hydration, and allows prompt correction by glove change, before the gloves lose their electrical and mechanical competence.
View details for Web of Science ID 000165180500010
View details for PubMedID 15348067
-
Hand and wrist injuries in young athletes
HAND CLINICS
2000; 16 (4): 597-?
Abstract
Successful treatments of musculoskeletal injuries in the pediatric population demand a thorough understanding of the basic anatomy and its biomechanics, and the physiology of growth and development of the immature skeleton. In addition, good treatment outcomes rely on the treating physician being an effective teacher to the young athlete and the patient's parents, coaches, and trainers. At the same time, the physician must be a good student in learning the nature of the patient's sports and each patient's athletic ability and aspirations. Most pediatric hand and wrist injuries can be treated nonoperatively with proper immobilization techniques and activity modification, but cases requiring surgical intervention must be recognized promptly to avoid long-term complications.
View details for Web of Science ID 000165582700011
View details for PubMedID 11117050
-
Virtual reality-based orthopedic telerehabilitation
IEEE TRANSACTIONS ON REHABILITATION ENGINEERING
2000; 8 (3): 430-432
Abstract
Rehabilitation interventions in remote areas are problematic because of distance and available resources. Orthopedic impairments acquired by individuals in remote areas can then lead to permanent disabilities/loss of function because of lack of appropriate rehabilitation. A system being developed by Rutgers and Stanford Universities provides therapy at the patient's home, with remote monitoring and periodic re-assessment. This telerehabilitation system uses virtual reality and haptic interfaces, and a pair of networked PCs. It is intended for rehabilitation of patients with hand, elbow, knee and ankle impairments. Data from the first patient treated with the telerehabilitation system is encouraging.
View details for Web of Science ID 000089336700019
View details for PubMedID 11001524
-
Plastic surgeons in American hand surgery: The past, present, and future
68th Annual Meeting of the American-Society-of-Plastic-and-Reconstructive-Surgeons
LIPPINCOTT WILLIAMS & WILKINS. 2000: 406–12
View details for Web of Science ID 000088631000025
View details for PubMedID 10946941
-
Presidential address: How shall we teach? How shall we learn? Educating hand surgeons in the new millennium.
journal of hand surgery
2000; 25 (4): 608-615
View details for PubMedID 10913200
-
Presidential address: How shall we teach? How shall we learn? Educating hand surgeons in the new millennium
54th Annual Meeting of the American-Society-for-Surgery-of-the-Hand
W B SAUNDERS CO-ELSEVIER INC. 2000: 608–15
View details for Web of Science ID 000088414900002
-
A virtual-reality-based telerehabilitation system with force feedback
IEEE TRANSACTIONS ON INFORMATION TECHNOLOGY IN BIOMEDICINE
2000; 4 (1): 45-51
Abstract
A PC-based orthopedic rehabilitation system was developed for use at home, while allowing remote monitoring from the clinic. The home rehabilitation station has a Pentium II PC with graphics accelerator, a Polhemus tracker, and a multipurpose haptic control interface. This novel interface is used to sample a patient's hand positions and to provide resistive forces using the Rutgers Master II (RMII) glove. A library of virtual rehabilitation routines was developed using WorldToolKit software. At the present time, it consists of three physical therapy exercises (DigiKey, ball, and power putty) and two functional rehabilitation exercises (peg board and ball game). These virtual reality exercises allow automatic and transparent patient data collection into an Oracle database. A remote Pentium II PC is connected with the home-based PC over the Internet and an additional video conferencing connection. The remote computer is running an Oracle server to maintain the patient database, monitor progress, and change the exercise level of difficulty. This allows for patient progress monitoring and repeat evaluations over time. The telerehabilitation system is in clinical trails at Stanford Medical School (CA), with progress being monitored from Rutgers University (NJ). Other haptic interfaces currently under development include devices for elbow and knee rehabilitation connected to the same system.
View details for Web of Science ID 000087173000006
View details for PubMedID 10761773
-
Polypeptide resurfacing method improves fibroblast's adhesion to hyaluronan strands
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH
1999; 47 (1): 79-84
Abstract
Hyaluronic acid (hyaluronan, HyA) is a matrix component that takes part in cell adhesion and growth in normal and repaired tissues. Since it is soluble in water, HyA has been of limited use in tissue engineering of artificial matrices. Recent studies demonstrate that polypeptides have the twin advantages of reducing solubility of HyA and improving cellular attachment via cell surface adhesion molecule receptors. This paper describes a new approach of using a polypeptide resurfacing method to enhance the attachment of cells to HyA strands. HyA strands were crosslinked by glutaraldehyde and then resurfaced with poly-D-lysine, poly-L-lysine, glycine, or glutamine. After inoculation with fibroblasts in vitro, modified HyA was evaluated with histological and immunohistochemical staining methods for cell adhesion and proliferation. Modified HyA with fibroblast cells also were implanted in vivo. The results show that (1) both polylysines enhanced fibroblast adhesion to crosslinked HyA strands; (2) HyA strands were able to be crosslinked well by 3 days of treatment in glutaraldehyde, and as a biomaterial they could resist biodegradation; (3) modified HyA has good biocompatibility, both in vitro and in vivo. The results demonstrate that HyA material resurfaced by polypeptides has positive advantages for cellular adhesion. Resurfaced HyA has much potential as an improved biomaterial for clinical usage.
View details for Web of Science ID 000081599800011
View details for PubMedID 10400884
-
Reconstructive hand surgery
SPINAL CORD
1999; 37 (7): 475-479
View details for Web of Science ID 000081524700004
View details for PubMedID 10438113
-
Posterior interosseous syndrome resulting from deep tissue massage
PLASTIC AND RECONSTRUCTIVE SURGERY
1998; 102 (5): 1778–79
View details for DOI 10.1097/00006534-199810000-00101
View details for Web of Science ID 000076285500098
View details for PubMedID 9774065
-
Fine-wire electromyographic recording during force generation - Application to index finger kinesiologic studies
AMERICAN JOURNAL OF PHYSICAL MEDICINE & REHABILITATION
1997; 76 (6): 494-501
Abstract
When accurately placed, fine-wire electrodes (FWEs) permit selective electromyographic recording during kinesiologic studies; however, their potential to limit contraction of the index finger muscles has not previously been evaluated. Given that these electrodes cannot be reinserted, reliable techniques are necessary to achieve proper placement while minimizing subject discomfort and electrode waste. The small size, close arrangement, and anatomic variability of hand and forearm muscles create challenges to achieving these goals. In this study, we simultaneously measured maximal fingertip forces and fine-wire electromyographic signals from all seven muscles of the index finger. Forces in five directions, with and without FWEs in place, were not statistically different (repeated-measures analysis of variance, P < 0.46) in five healthy adult subjects. To guide electrode placement, we identified skin penetration landmarks, direction of needle advancement, and depth of muscle fibers. Fibers of flexor digitorum superficialis and flexor digitorum profundus to the index finger were more distal than depicted in textbooks, requiring electrode placement at or distal to the midpoint of the forearm. For these muscles and the extensor digitorum, locating the desired fibers first with a monopolar needle electrode facilitated subsequent FWE placement. For the dorsal and palmar interossei, lumbrical, and extensor indicis proprius, insertion was aided by concurrent monitoring of the electromyographic signals. We achieved a 93% success rate during FWE placement in a total of 60 muscles. Techniques for recording from each of the seven index finger muscles are described.
View details for Web of Science ID 000071234100010
View details for PubMedID 9431269
-
Enhancement of axon growth by detergent-extracted nerve grafts
TRANSPLANTATION
1997; 63 (9): 1210-1215
Abstract
The immunogenicity of nerve allografts is responsible for their rejection. We have developed a method for preparing cell-free nerve grafts using lysophosphatidylcholine to remove cells, axons, and myelin sheaths.The remaining intact nerve extracellular matrix is the extracted nerve graft (eNG). Cultured neonatal Schwann cells were micro-injected into the eNG to form recellularized nerve grafts (rNG). eNG, rNG, and normal isografts (15 mm long) were implanted in the peroneal nerves of F-344 rats. Ten rats were given an eNG on the right, and an isograft on the left. Ten rats were given an rNG on the right, and a sham operation on the left. Sham operation was used as the control and the isograft was used as the benchmark procedure. Walking track analysis was performed every 15 days after surgery to determine the peroneal functional index. Morphometric analysis of the distal peroneal nerve and extensor digitorum muscle weight were analyzed 3 months after surgery.The three types of grafted legs had the classical effect observed after peripheral nerve repair, with decreased functional ability, decreased target muscle weight, fewer large nerve fibers, and more small nerve fibers. Isografts, eNG, and rNG all had similar patterns of peroneal functional index improvement after implantation. The extensor digitorum longus muscle weight and axon counts for the three types of graft were not statistically different. Hence, eNG and rNG can enhance nerve regeneration in the same way as isografts. The host Schwann cells that invaded the implanted eNG probably acted in the same fashion as the cultured Schwann cells injected into the rNG and the resident cells of isografts.The great permeability of the longitudinally oriented matrix of eNG to cells is, therefore, a major advantage over the reported poor permeability of freeze-thawed nerve grafts.
View details for Web of Science ID A1997WZ23100004
View details for PubMedID 9158011
-
Vascularized toe joint transfer to the hand
PLASTIC AND RECONSTRUCTIVE SURGERY
1996; 98 (7): 1275-1284
Abstract
From 1984 to 1993, 36 vascularized toe joints were transferred in 33 patients. The present study group excludes 3 toe joint transfers to elbow and temporomandibular joints and 4 toe joint to hand transfers lost to follow-up. The final study group includes 29 vascularized toe joint transfers in 27 patients, 21 males and 6 females. All were performed for posttraumatic reconstruction, except one transfer for congenital deformity. Follow-up averaged 32.4 months. Mean range of motion was 34 degrees in toe metatarsophalangeal joint to hand metacarpophalangeal joint transfers, 32 degrees in toe proximal interphalangeal joint to hand metacarpophalangeal joint transfers, and 24 degrees in toe proximal interphalangeal joint to hand proximal interphalangeal joint transfers. Although vascularized toe joint transfer is an alternative to arthrodesis, in order to have a greater range of motion than average, the patient must have well-functioning muscle and associated tendons effecting joint motion. Good results were obtained in two immediate free vascularized toe joint transfers to complex injuries involving loss of the metacarpophalangeal joint. We encourage toe joint transfer in selected complex hand injuries.
View details for Web of Science ID A1996VV74400025
View details for PubMedID 8942916
-
A composite nerve graft system: Extracted rat peripheral nerve injected with cultured Schwann cells
MUSCLE & NERVE
1996; 19 (1): 97-99
View details for Web of Science ID A1996TM00100017
View details for PubMedID 8538678
- Surgical reconstruction in tetraplegia. Procedure and Hand Surgery. - 1996
-
ACTION-POTENTIALS OF CURVED NERVES IN FINITE LIMBS
IEEE TRANSACTIONS ON BIOMEDICAL ENGINEERING
1995; 42 (6): 599-607
Abstract
Previous simulations of volume-conducted nerve-fiber action-potentials have modeled the limb as semi-infinite or circularly cylindrical, and the fibers as straight lines parallel to the limb surface. The geometry of actual nerves and limbs, however, can be considerably more complicated. This paper presents a general method for computing the potentials of fibers with arbitrary paths in arbitrary finite limbs. It involves computing the propagating point-source response (PPSR), which is the potential arising from a single point source (dipole or tripole) travelling along the fiber. The PPSR can be applied to fibers of different conduction velocities by simple dilation or compression. The method is illustrated for oblique and spiralling nerve fibers. Potentials from oblique fibers are shown to be different for orthodromic and antidromic propagation. Such results show that the straight-line models are not always adequate for nerves with anatomical amounts of curvature.
View details for Web of Science ID A1995QZ19900008
View details for PubMedID 7790016
-
SHORT GRACILIS MYOCUTANEOUS FLAPS FOR VULVOPERINEAL AND INGUINAL RECONSTRUCTION
PLASTIC AND RECONSTRUCTIVE SURGERY
1995; 95 (2): 372-377
Abstract
From October of 1990 to April of 1993, 16 short gracilis myocutaneous flaps and 1 short gracilis muscular flap were used to reconstruct vulvoperineal, inguinal, perineal, and ischial soft-tissue defects. Five of the 6 bilateral myocutaneous flaps were used for vulvoperineal reconstruction after radical vulvectomy combined with partial vaginectomy and one radical vulvectomy. Four unilateral myocutaneous flaps and one muscular flap were used for inguinal, suprapubic, ischial, and perineal reconstruction after release of contracted scar or excision of an ischial pressure sore. The immediate complications consisted of partial necrosis of the distal third of the cutaneous tissue in 6 patients, 1 superficial cutaneous necrosis, and superficial wound infection in 7 patients. The muscular portion of the flaps all survived. The follow-up period was from 6 to 27 months. The short gracilis flap has greater mobility than the classically described gracilis flap. On the basis of the functional and cosmetic results, the short gracilis flap is an excellent alternative to the more bulky classic gracilis flap.
View details for Web of Science ID A1995QE56400018
View details for PubMedID 7824617
- The role of microsurgical flap procedure in a medical center. Advances in Plastic and Reconstructive Surgery. 2 - 1995
- Thumb reconstruction and pollicization by conventional techniques. Mastery of Plastic and Reconstructive Surgery. - 1994
-
EXTENSOR DIGITI-MINIMI TENDON TRANSFER TO PREVENT RECURRENT ULNAR DRIFT
PLASTIC AND RECONSTRUCTIVE SURGERY
1993; 92 (3): 507-510
Abstract
Thirty percent of patients with rheumatoid arthritis develop ulnar drift. Although numerous operations have been described, recurrence of the deformity is frequent. We recommend use of the extensor digiti minimi tendon transfer to prevent recurrent ulnar deviation. The tendon insertion is moved from a dorsal location to a dorsal-radial position. In this new location, the tendon produces both extension and radial deviation. Moreover, this transfer is maximally effective in extension when ulnar drift is greatest. We have used this transfer 28 times during the past 6 years. In evaluating patients more than 1 year after surgery, metacarpal phalangeal joint extension averaged 52 degrees and there was no evidence of recurrent ulnar drift of the little finger. The only problem was slight hyperextension of less than 5 degrees in approximately half of the patients. However, in no patient was this functionally a problem. We recommend the use of this tendon transfer in all patients with ulnar drift undergoing metacarpal phalangeal joint replacement for rheumatoid arthritis.
View details for Web of Science ID A1993LR60800020
View details for PubMedID 8341752
-
The nerve gap dilemma: a comparison of nerves repaired end to end under tension with nerve grafts in a primate model.
journal of hand surgery
1993; 18 (3): 417-425
Abstract
The objective of this study was to compare, in a clinically relevant primate model, axon regeneration after epineurial repair under tension (15 mm gap) with interfascicular nerve grafts with the use of either standard microsuture techniques or a new interfascicular nerve graft technique termed fascicular tubulization that uses a hypoantigenic collagen membrane formed into a tube to approximate nerve ends. Electrophysiologic analysis demonstrated that the percentage of proximal axons that conducted across the repair site was greater in those nerves repaired under tension with epineurially placed sutures than in either of the tensionless repairs involving interfascicular graft techniques. The mean diameters of the regenerated axons repaired under tension with epineurial sutures were greater than those of the nerves repaired with interfascicular grafts, although the difference was not statistically significant. Interfascicular nerve grafting with tubulization using the current collagen tube resulted in regeneration equal to the sutured interfascicular nerve grafts. For modest defects (perhaps up to 3 to 4 cm in the adult), it seems advantageous to accept the modest tension associated with an epineurial repair rather than to use an autograft (or artificial graft) to achieve a tension-free repair.
View details for PubMedID 8515008
-
THE NERVE GAP DILEMMA - A COMPARISON OF NERVES REPAIRED END-TO-END UNDER TENSION WITH NERVE GRAFTS IN A PRIMATE MODEL
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
1993; 18A (3): 417-425
Abstract
The objective of this study was to compare, in a clinically relevant primate model, axon regeneration after epineurial repair under tension (15 mm gap) with interfascicular nerve grafts with the use of either standard microsuture techniques or a new interfascicular nerve graft technique termed fascicular tubulization that uses a hypoantigenic collagen membrane formed into a tube to approximate nerve ends. Electrophysiologic analysis demonstrated that the percentage of proximal axons that conducted across the repair site was greater in those nerves repaired under tension with epineurially placed sutures than in either of the tensionless repairs involving interfascicular graft techniques. The mean diameters of the regenerated axons repaired under tension with epineurial sutures were greater than those of the nerves repaired with interfascicular grafts, although the difference was not statistically significant. Interfascicular nerve grafting with tubulization using the current collagen tube resulted in regeneration equal to the sutured interfascicular nerve grafts. For modest defects (perhaps up to 3 to 4 cm in the adult), it seems advantageous to accept the modest tension associated with an epineurial repair rather than to use an autograft (or artificial graft) to achieve a tension-free repair.
View details for Web of Science ID A1993LE81800006
- Reconstruction of brachial plexus injuries. Operative Hand Surgery. - 1993
-
Rehabilitation and surgical reconstruction of the upper limb in tetraplegia: an update.
journal of hand surgery
1992; 17 (5): 964-967
View details for PubMedID 1401816
-
REHABILITATION AND SURGICAL RECONSTRUCTION OF THE UPPER LIMB IN TETRAPLEGIA - AN UPDATE
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
1992; 17A (5): 964-967
View details for Web of Science ID A1992JN89100035
-
A PRACTICAL GUIDE TO INTERNATIONAL LEECH TRANSPORTATION
ANNALS OF PLASTIC SURGERY
1992; 29 (3): 282-283
View details for Web of Science ID A1992JL75400018
View details for PubMedID 1524383
-
A COMPARISON OF SUTURE AND TUBULIZATION NERVE REPAIR TECHNIQUES IN A PRIMATE
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
1991; 16A (2): 251-261
Abstract
This study compared standard methods of nerve repair, epineurial or perineurial sutures with a technique termed fascicular tubulization using a biodegradable polyglycolic acid tube in a nonhuman primate model. Electrophysiologic analysis demonstrated that the percentage of proximal axons that conducted across the repair site did not significantly differ among the three techniques while epineurial suture repairs were associated with significantly longer conduction delays across the repair site compared with the other two techniques. Even though fascicular tubulization using the current polyglycolic acid tube resulted in regeneration equal to the currently perceived best suture repair technique, associated technical problems with the current tube design indicate that this fascicular tubulization technique cannot, at present, be considered as an alternative to present clinically used nerve suture techniques.
View details for Web of Science ID A1991FA98700011
-
BRACHIAL-PLEXUS MICROSURGERY IN CHILDREN
MICROSURGERY
1991; 12 (3): 175-185
Abstract
From this review, the following points have emerged: 1. The typical obstetrical palsy is a traumatic lesion caused by forced lowering of the shoulder during delivery. 2. While the lesion may affect all the roots, the upper roots are usually ruptured, whereas the lower roots (if involved) are always avulsed. 3. Spontaneous recovery is possible, but its quality depends on how early recovery of previously paralyzed muscles begins. If the biceps have not started to recover by 3 months, the final result will be poor. It is at this time interval that a surgical decision should be made. 4. Surgical repair is always possible, usually by grafting, though repair can be difficult if significant numbers of avulsions have occurred. 5. The results of surgical reconstruction are better than are the results of spontaneous evolution, at least in those patients who reach the age of 3 months without evidence of recovery of the biceps. For example, more than half of the patients recover a nearly normal shoulder after grafting C5, C6 lesions in Gilbert's series, whereas in the same control population of patients, none achieved this result spontaneously. 6. Palliative treatment of the sequelae of birth palsies is difficult, and the results obtained are rarely totally satisfactory. It is for these reasons that the initial surgical intervention should be on the plexus itself in those instances meeting the criteria established above. It is important to make this decision as quickly as possible before neuroplasticity is diminished and joint contractions have occurred.
View details for Web of Science ID A1991FL70700006
View details for PubMedID 1865811
-
PRELIMINARY EXPERIMENTS IN NERVE REGENERATION THROUGH LASER-DRILLED HOLES IN SILICON CHIPS
RESTORATIVE NEUROLOGY AND NEUROSCIENCE
1990; 2 (2): 89-102
Abstract
Many of the present limitations of peripheral nerve repair might be overcome by performing nerve repairs at the axon level. One approach to nerve repair at this level would be to implant a neuroprosthesis in the form of a microelectronic switchboard which could route the connections of regenerated axons to their correct destinations. This requires a merger of microsurgery and microelectronics. Three steps are needed to achieve this goal. (1) The achievement of in vivo compatibility and electrical contact between axons and a material compatible with microelectronics. (2) The fabrication of a microelectronic neuroprosthesis with electrodes to establish communication with the axon. (3) The development of signal processing hardware and software to control the mapping of the regenerated axons. This report describes preliminary experiments in regenerating peripheral nerve axons through an electronic-grade silicon chip with laser-drilled holes small enough to capture either one or a few axons per hole. We have observed the viability of such nerves in 4 rats for 6 months to 1 year, and in two primates for more than 3 months. As our experiments show, this technique is not yet as effective as suture repair, but the development of a neuroprosthesis that communicates with peripheral nerve axons could have applications including nerve repair, neuroma, and nerve grafts, as well as interfacing the peripheral nervous system to prostheses of other kinds.
View details for Web of Science ID A1990EV45700005
View details for PubMedID 21551590
-
Cloward technique for obtaining iliac crest bone graft in hand surgery.
journal of hand surgery
1990; 15 (1): 181-183
View details for PubMedID 2299162
-
CLOWARD TECHNIQUE FOR OBTAINING ILIAC CREST BONE-GRAFT IN HAND SURGERY
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
1990; 15A (1): 181-183
View details for Web of Science ID A1990CK26200033
-
DIGIT REPLANTATION APPLYING THE LEECH HIRUDO-MEDICINALIS
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
1989: 133-137
Abstract
Digits that were formerly assessed as nonreplantable may now be replanted with the help of the leech Hirudo medicinalis. The early experience with a series of patients who had relative contraindications for replantation is reported. In each case, venous repair was either marginal or technically impossible. Postoperative venous congestion developed following replantation and was treated with the application of medicinal leeches. Patient acceptance was high, and no infections developed. No patient required transfusion. The authors conclude that the use of medicinal leeches shows promise as a safe and effective method of providing temporary venous drainage in replanted digits.
View details for Web of Science ID A1989AJ74100020
View details for PubMedID 2752613
-
FASCICULAR TUBULIZATION - A COMPARISON OF EXPERIMENTAL NERVE REPAIR TECHNIQUES IN THE CAT
ANNALS OF PLASTIC SURGERY
1989; 22 (6): 467-478
Abstract
Peripheral nerve repair remains one of the most difficult problems in hand surgery; the results of conventional epineurial and fascicular suture repair are a major limitation to the rehabilitation of the patient. The aim of this study was to evaluate a tubulization technique of nerve repair by wrapping a membrane of hypoantigenic collagen around the nerve at the fascicular level. Cat ulnar and median nerves were used as a multifascicular nerve model. Thirty-eight animals were studied. Ten animals were included in long-term studies comparing fascicular tubulization to either epineurial suture or fascicular suture nerve repair. Histologically, the tube repairs demonstrated improved organization at the repair site compared with either suture technique. Tube repair is not significantly different statistically by quantitative histological and physiological evaluation methods from epineurial suture or fascicular suture repairs. Further studies in more clinically applicable animal models are required before this technique can be considered as an alternative to present clinical nerve suture techniques.
View details for Web of Science ID A1989AC14600002
View details for PubMedID 2751220
-
EXPERIENCE WITH THE ISLAND RADIAL FOREARM FLAP IN LOCAL HAND COVERAGE
JOURNAL OF TRAUMA-INJURY INFECTION AND CRITICAL CARE
1989; 29 (4): 489-493
Abstract
Use of the island radial forearm flap (RFF) for soft-tissue coverage of hand and forearm following mutilating injuries, chemotherapeutic injection sloughs, and tumor excisions are discussed. Twenty-eight flaps were used in 28 injured upper extremities. Partial flap loss occurred in three patients. Minor sloughing of the skin graft of the donor site occurred in four. Twelve patients had persistent dysesthesias and paresthesias in the injured extremity. All patients complained of some degree of weakness in the injured extremity. Our experience supports the use of this flap for local hand and forearm coverage when local tissue is unavailable and skin grafting is deemed inadvisable. Donor site problems have been acceptable in our patient population.
View details for Web of Science ID A1989U467900012
View details for PubMedID 2540345
-
EFFECT OF LOW-FREQUENCY LOW-ENERGY PULSING ELECTROMAGNETIC-FIELD (PEMF) ON X-RAY-IRRADIATED MICE
EXPERIMENTAL HEMATOLOGY
1989; 17 (2): 88-95
Abstract
C3H/Km flora-defined mice were used to investigate the effect of exposure to pulsing electromagnetic field (PEMF) after total body x-ray irradiation. Prolonged exposure to PEMF had no effect on normal nonirradiated mice. When mice irradiated with different doses of x-ray (8.5 Gy, 6.8 Gy, and 6.3 Gy) were exposed to PEMF 24 h a day, we observed a more rapid decline in white blood cells (WBC) in the peripheral blood of mice exposed to PEMF at all the x-ray dosages used. No effect of exposure to PEMF was observed on the survival of the mice irradiated with 6.3 Gy and 8.5 Gy; in mice irradiated with 6.8 Gy, 2 out of 12 survived when exposed to PEMF as compared to 10 out of 12 control mice that were irradiated only. At day 4 after irradiation autoradiographic studies performed on bone marrow and spleen of 8.5-Gy-irradiated mice showed no difference between controls and mice exposed to PEMF, whereas on 6.8-Gy mice the bone marrow labeling index was lower in mice exposed to PEMF. In mice irradiated to 6.3 Gy we observed that the recovery of WBC in the peripheral blood was slowed in mice exposed to PEMF and their body weight was significantly lower than in control mice that were irradiated only. The spleen and bone marrow of the mice irradiated to 6.3 Gy and sacrificed at days 4, 14, 20, and 25 after irradiation were analyzed by autoradiography to evaluate the labeling index. Half of the spleens from mice sacrificed at day 25 after irradiation were used to evaluate the RNA content. Autoradiography showed that in the spleen and bone marrow of control mice, there were more cells labeled with [3H]thymidine at days 4 and 14 and less at days 20 and 25 after irradiation in comparison with mice irradiated and exposed to PEMF. The Northern blot analysis of histone H3 and p53 protein RNAs extracted from the spleens at day 25 after irradiation showed a slight increase in cycling cells among spleens of mice exposed to PEMF. We suggest that the exposure to PEMF immediately after x-ray irradiation results in increased damage.
View details for Web of Science ID A1989T025300004
View details for PubMedID 2643520
-
Artificial nerve graft compared to autograft in a rat model.
Journal of rehabilitation research and development
1989; 26 (1): 1–14
Abstract
A study was made to compare the regeneration of rat peroneal nerve across a 0.5 cm gap repaired with a sutured autograft (SAG) versus an artificial nerve graft (ANG). The ANG model is composed of a synthetic biodegradable passive conduit made of polyglycolic acid (PGA) and a synthetic growth medium composed of hypoallergenic collagen. Axonal regeneration in short-term animals (1 and 4 months) was evaluated by qualitative histology only, while in long-term animals (17 to 21 months) quantitative histology and electro-physiology were used in addition to qualitative histology. This study reveals that axons do regenerate through this ANG model, but electrophysiological analyses show that the axonal regeneration is statistically inferior to that in the SAG. There was no significant statistical difference in the quantitative histological data.
View details for PubMedID 2537422
-
NEUROTIZATION IN BRACHIAL-PLEXUS INJURIES - INDICATION AND RESULTS
CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
1988: 43-56
Abstract
In neurotization or nerve transfer, a healthy but less valuable nerve or its proximal stump is transferred in order to reinnervate a more important sensory or motor territory that has lost its innervation through irreparable damage to its nerve. In brachial plexus injuries, extraplexal nerves such as the spinal accessory nerve, rami of the cervical plexus, or intercostal nerves are transferred onto trunks, cords, or individual nerves or else segments of the brachial plexus that maintain continuity with the spinal cord may be coapted to trunks or cords the surgeon wishes to innervate. This method is particularly indicated in root avulsion injuries that occur frequently following traction trauma to the brachial plexus. The authors convey their experience with neurotization using the long thoracic nerve in seven cases, the accessory nerve in 30 cases, intercostal nerves in 66 cases, and various nerve transfers within the plexus in 31 cases. Results of other authors are also reported. With these methods, it is possible to obtain good elbow flexion in more than one-half of patients; however, only limited shoulder function and no useful finger function are obtained.
View details for Web of Science ID A1988R228100008
View details for PubMedID 3056647
-
AN APPROACH TO MANDIBULAR RECONSTRUCTION
ANNALS OF PLASTIC SURGERY
1988; 21 (5): 401-417
Abstract
Mandibular reconstruction requires the restitution of both form and function. Proper preoperative planning, vascularized bone grafts, rigid fixation, flexibility of donor site choices, and restoration of labial, buccal, and lingual sulci lead to optimal reconstruction. We have used this approach in 38 patients; bony survival resulted in 37 and primary union in 35. A main limiting factor exists with individuals who have lost extensive amounts of soft tissue and muscle at the time of tumor resection or trauma. Only by attention to details in the preoperative, intraoperative, and postoperative phases can the best functional and aesthetic results be achieved.
View details for Web of Science ID A1988Q973500002
View details for PubMedID 3069032
-
SURGICAL RECONSTRUCTION IN TETRAPLEGIA
HAND CLINICS
1988; 4 (4): 601-607
Abstract
The authors reviewed their 10 years of combined experience in the surgical reconstruction of the upper extremities in 170 quadriplegic patients from two spinal cord treatment centers. The authors' current recommendations regarding patient selection are presented, refinements in previously published surgical techniques are defined, and the principles of postoperative care are discussed.
View details for Web of Science ID A1988R233000006
View details for PubMedID 3073162
-
NAPROXEN SODIUM VERSUS ACETAMINOPHEN-CODEINE FOR PAIN FOLLOWING PLASTIC-SURGERY
CURRENT THERAPEUTIC RESEARCH-CLINICAL AND EXPERIMENTAL
1988; 43 (2): 311-316
View details for Web of Science ID A1988M287700015
-
REPETITIVE TRAUMA AND NERVE COMPRESSION
ORTHOPEDIC CLINICS OF NORTH AMERICA
1988; 19 (1): 157-164
Abstract
Repetitive movement of the upper extremity, whether recreational or occupational, may result in various neuropathies, the prototype of which is the median nerve neuropathic in the carpal canal. The pathophysiology of this process is incompletely understood but likely involves both mechanical and ischemic features. Experimentally increased pressures within the carpal canal produced reproducible progressive neuropathy. Changes in vibratory (threshold-type) sensibility appears to be more sensitive than two-point (innervation density-type) sensibility. The specific occupational etiologies of carpal neuropathy are obscured by methodologic and sociological difficulties, but clearly some occupations have high incidences of CTS. History and physical examination are usually sufficient for the diagnosis, but diagnostic assistance when required is available through electrophysiological testing, CT scanning, and possibly MRI. Each of these tests has limitations in both sensitivity and specificity. Treatment by usual conservative means should be combined with rest from possible provocative activities. Surgical release of the carpal canal is helpful in patients failing conservative therapy. Occupational modifications are important in both treatment and prevention of median neuropathy due to repetitive trauma.
View details for Web of Science ID A1988L630200015
View details for PubMedID 3275923
-
DESIGN AND IMPLEMENTATION OF 2-DIMENSIONAL NEURAL INTERFACES
1989 ANNUAL INTERNATIONAL CONF OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOC
I E E E. 1988: 1649–1650
View details for Web of Science ID A1988BP88P00849
-
THE RESULTS OF MICRONEUROSURGICAL RECONSTRUCTION IN COMPLETE BRACHIAL-PLEXUS PALSY - ASSESSING OUTCOME AND PREDICTING RESULTS
ORTHOPEDIC CLINICS OF NORTH AMERICA
1988; 19 (1): 107-114
Abstract
The outcome of microsurgical reconstruction in 114 adult patients presenting with complete traumatic brachial plexus palsy was analyzed. The authors examined the effects of age, time since injury, operative findings, and the techniques of reconstruction on the level of muscle recovery. Statistical and analytic computer programs were used in an attempt to determine what factors most influenced recovery.
View details for Web of Science ID A1988L630200010
View details for PubMedID 3336570
-
THE RADIAL FOREARM FLAP - A VERSATILE SOURCE OF COMPOSITE TISSUE
ANNALS OF PLASTIC SURGERY
1987; 19 (6): 485-498
Abstract
The radiovolar area of the forearm constitutes a versatile source of composite tissues for pedicle flap reconstruction of the hand and free-flap reconstruction for many areas of the body. The skin is thin and relatively hairless, and the vascular pedicle is long and of large caliber. The flap can be harvested to contain vascularized tendons and bone. The skin can be reliably reinnervated. The principal disadvantage, that this is a conspicuous donor site, has not been a source of concern for our patients. Nineteen of the 20 (95%) free flaps survived completely.
View details for Web of Science ID A1987L530700001
View details for PubMedID 3439761
-
Application of free tissue transfers to the foot.
Journal of reconstructive microsurgery
1987; 3 (4): 309-320
Abstract
During the past five years we have used three sources of free tissue transfers in 26 patients to reconstruct defects of the ankle and dorsum, hind, mid- and forefoot, defects poorly or unamenable to traditional reconstructive methods. These included free muscle transfers covered with a skin graft, temporoparietal fascia also covered with a graft, and radial forearm skin or fascia. In addition, six complex defects were reconstructed with composite tissue free transfers, usually tendinocutaneous flaps. There was one partial flap loss. All were successful in both healing the defect and in providing functional restoration, except in the forefoot. From an analysis of these cases, we have developed indications for various transfers based on the functional needs of the area involved and donor site requirements.
View details for PubMedID 2888887
-
IMAGING STUDIES OF THE CADAVER HAND USING TRANSMISSION ULTRASOUND
SKELETAL RADIOLOGY
1987; 16 (6): 474-480
Abstract
Ultrasonic transmission imaging has already demonstrated potential for evaluating structures in the hand. In this study, a cadaver hand was imaged using a transmission scanner with improved imaging capability. The hand was then frozen and serially sectioned and comparisons were made between the sectional anatomy and the corresponding image. Bone (in silhouette), muscle, cartilage, and tendon were visualized with high resolution.
View details for Web of Science ID A1987J669100008
View details for PubMedID 3310247
-
Hand reconstruction following avulsion of all dorsal soft tissues. A cutaneo-tendinous free tissue transfer.
Annales de chirurgie de la main : organe officiel des sociétés de chirurgie de la main
1987; 6 (1): 31-37
Abstract
Restoration of function following mutilating injuries to the extensor surface of the hand has traditionally involved staged reconstruction with distant pedicle flaps, followed by tendon grafting. Advances in microsurgery now permit the transfer, in one operation, of vascularized composite tissues such as skin and muscle, or skin and bone. For dorsal hand reconstruction a composite flap of skin, tendons and nerves from the dorsum of the foot was transferred in one stage soon after injury, avoiding unnecessary disabling scar formation, prolonged hospitalization and resulting in the rapid restoration of near normal function and appearance of the hand. Donor site morbidity was minimal.
View details for PubMedID 3304176
-
OUR EXPERIENCE WITH THE EFFECTS OF PEMFS ON LECTIN-INDUCED LYMPHOCYTE-PROLIFERATION
MARCEL DEKKER INC. 1987: 258–60
View details for Web of Science ID A1987L998800027
-
CONGENITAL-ANOMALIES - LOOKING AHEAD
CLINICS IN PLASTIC SURGERY
1986; 13 (2): 175-189
Abstract
The management of upper limb congenital anomalies has been affected by modern techniques and technology and shaped by socioeconomic influences. Future technologic advances will have a major impact on tomorrow's diagnosis and treatment.
View details for Web of Science ID A1986C056000003
View details for PubMedID 3698476
-
SALVAGE OF THE EXPOSED BREAST IMPLANT
ANNALS OF PLASTIC SURGERY
1986; 16 (2): 106-110
Abstract
Exposure of silicone breast implants may occur as a result of hematoma and infection, inadequate soft tissue coverage, use of steroids, or trauma. In various series the incidence of severe complications is reported to range from 1% to 4%. When exposure of the implant has occurred, most authors recommend removal with replacement four to six months later. In 11 patients we successfully salvaged the exposed breast implant. The technique was initially presented in 5 patients in 1974. Successful salvage of the exposed implant involved (1) wound cultures with preoperative and postoperative antibiotic therapy, (2) excisional debridement of the skin wound, (3) open capsulotomy to relieve tension, (4) wound irrigation with neomycin-polymyxin or povidone-iodine, (5) closed catheter drainage, and (6) replacement with a sterile prosthesis. Secondary closure of these wounds was successful in all of the patients. Of the 11 patients, 9 were seen at two years postoperatively with results comparable in appearance and softness to the opposite breast. One of the patients required subsequent bilateral capsulotomies for firmness. The use of this technique is recommended for selected patients in whom there are no systemic problems related to wound healing and in whom sufficient soft tissue coverage is possible.
View details for Web of Science ID A1986A150500005
View details for PubMedID 3273018
-
EXPERIENCE WITH THE TEMPOROPARIETAL FASCIAL FREE FLAP
PLASTIC AND RECONSTRUCTIVE SURGERY
1985; 76 (2): 177-188
Abstract
The temporoparietal fascia is an ideal tissue source for free transfer to distant sites where ultrathin coverage is either desirable or mandatory. The fascia's dependable vascular anatomy facilitates the technical aspects of microvascular transfer by means of its large vessels, ample pedicle, and ability to be grafted on either side. Furthermore, this highly vascular tissue is available in surprisingly large quantities, and its donor scar is hidden in the hair. The authors have found this flap useful (1) in covering exposed bone and tendon without adding unwanted bulk, (2) in providing thin flap coverage or lining in major facial reconstruction, (3) in covering vital structures such as exposed nerves and vessels, (4) in providing neovascularity both as a recipient graft bed and for control of chronic infection, and (5) in reestablishing gliding-tendon mechanisms. The authors have successfully employed this free flap in 15 cases which involved deformities of the ankle, foot, Achilles tendon, forearm, hand, nose, and contralateral ear and scalp. Seven cases are utilized to illustrate the broad application of this unique and versatile free flap.
View details for Web of Science ID A1985AMV3000001
View details for PubMedID 4023091
-
A DOUBLE-SPLIT GLUTEUS MAXIMUS MUSCLE FLAP FOR RECONSTRUCTION OF THE RECTAL SPHINCTER - DISCUSSION
PLASTIC AND RECONSTRUCTIVE SURGERY
1985; 75 (1): 67-67
View details for Web of Science ID A1985TY21800014
-
USE OF CYCLOSPORIN-A IN ALLOTRANSPLANTATION OF RAT LIMBS
ANNALS OF PLASTIC SURGERY
1984; 12 (3): 249-255
Abstract
An experimental model for limb transplantation as a composite tissue transfer has been developed using two genetically well defined strains of rats, BUF and LEW. The study shows that cyclosporin A (CyA) is very effective as an immunosuppressive agent in preventing rejection of transplanted limbs in rats. It is found to suppress rejection of the homotransplants as long as treatment is continuous. No untoward side effects have been noted at the current experimental dosage of the medication. CyA is superior to the conventional agents, such as azathioprine and prednisolone, which allow rejection of the limbs while treatment is in progress. There is a period of immune tolerance following CyA treatment; however, this period becomes shorter as the length of the treatment is increased. This may indicate that CyA treatment should be continuous and not pulsed at the dosage used in this experimental model. Additional experiments are underway to further elucidate this phenomenon.
View details for Web of Science ID A1984SJ09700005
View details for PubMedID 6609665
-
PRELIMINARY-STUDY OF THE UPPER LIMB WITH THE USE OF ULTRASOUND TRANSMISSION IMAGING
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
1984; 9A (2): 188-193
Abstract
A biologically safe, noninvasive method for visualizing bone and soft tissue relationships has been developed recently. Termed the ultrasonic transmission imaging system, its advantages include visualization of soft tissues in real time while motion is underway. The image can be correlated to standard x-ray films, but since no ionizing radiation is involved, repeated risk-free visualization of extremities for either diagnostic assessment or biomechanical studies is permitted. Resolution of 1 mm and a depth of field of 8 mm are adequate for visualization of neurovascular bundles, tendons, ligaments, bones, and joints. The image can be digitized and stored for later analysis on computer graphic systems. Pilot studies have correlated the ultrasonic anatomy of normal and abnormal living and cadaver hands with known anatomic structures. The benefits to biomechanical analysis include the ability to visualize and accurately measure in a noninvasive manner the in vivo changes of position of tendons and other structures during movement. These initial efforts indicate the growing diagnostic and analytic capabilities of this instrument.
View details for Web of Science ID A1984SL36000007
-
INJECTABLE IBUPROFEN - PRELIMINARY EVALUATION OF ITS ABILITY TO DECREASE PERITENDINOUS ADHESIONS
ANNALS OF PLASTIC SURGERY
1984; 13 (6): 459-467
Abstract
Peritendinous adhesions continue to limit the full return of hand function following flexor tendon injury and repair. Pilot studies in rabbits demonstrated the ability of ibuprofen (Motrin) to reduce intra-abdominal adhesions. In this study, ibuprofen injected at the site of flexor tendon repair significantly reduced the restrictive effects of peritendinous adhesions in primates.
View details for Web of Science ID A1984TW36600001
View details for PubMedID 6524841
-
UPPER LIMB RECONSTRUCTION IN QUADRIPLEGIA - FUNCTIONAL ASSESSMENT AND PROPOSED TREATMENT MODIFICATIONS
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
1983; 8 (2): 119-131
Abstract
The functional results following reconstruction of key grip (40 limbs in 30 patients) and active elbow extension (14 limbs in 9 patients) in higher spinal level quadriplegic patients were reviewed and results were classified as follows: Good result (55% of operated limbs)--Patients were very pleased with the greater ease and capabilities in performing functional activities. Fair result (30%)--Patients were moderately satisfied; thumb instability and poor finger position during pinch were the two greatest sources of dissatisfaction. Poor result (15%)--Patients were disappointed, usually because of progressive contracture, spasticity, or pain. On preoperative assessment, these were the weakest patients or those who had the longest interval between injury and surgery. In 10 of 14 limbs functionally active elbow extension was obtained, although the long convalescent time was a deterrent. Based on these results, the modifications in the following areas of treatment protocol were made: (1) Patient selection--Of those patients with only minimum levels of functional resources, only the most highly motivated should have elective reconstructive surgery. (2) Surgical technique--Procedures to better stabilize the thumb metacarpophalangeal joint and to assist in positioning the other digits during pinch include a stronger tenodesis of the thumb extensor tendons to the metacarpal and tenodesis of the superficialis tendons of the index and long fingers to the proximal phalanx. Other procedures include modification of the methods of attachment of tendon transfers to shorten convalescence following reconstruction of active elbow extension. (3) Postoperative care--postoperative problems develop insidiously. Frequent reassessment is mandatory.
View details for Web of Science ID A1983QF02500001
View details for PubMedID 6833719
-
THE IRREPLACEABLE FREE FLAP .2. SKELETAL RECONSTRUCTION BY MICROVASCULAR FREE BONE TRANSFER
ANNALS OF PLASTIC SURGERY
1983; 10 (1): 43-54
View details for Web of Science ID A1983PY62700006
View details for PubMedID 6338798
-
FASCICULAR TUBULIZATION - A CELLULAR APPROACH TO PERIPHERAL-NERVE REPAIR
ANNALS OF PLASTIC SURGERY
1983; 11 (5): 397-411
Abstract
Present techniques of nerve repair by suture are based on an anatomical approach. The severed layers of connective tissue are reapproximated. Another approach to nerve repair is to separate the specific cellular components of the peripheral nerve that contribute to fibrous healing and nerve regeneration. The perineurium normally separates the extrafascicular epineurium of mesodermal origin from the intrafascicular endoneurium of ectodermal origin. A cellular approach to nerve repair would use a tube around the fascicle as an artificial perineurium to separate fibrous healing from axonal regeneration until the perineurium reestablishes its continuity. Fascicular tubulization with polyglycolic acid tubes was studied in 25 rats. The polyglycolic acid tube is resorbed after the perineurium has reestablished its continuity. The repairs by fascicular tubulization demonstrated improved organization of the repair site compared to suture repairs. The diameter histograms of the regenerated myelinated axons were similar in repairs by tube and suture techniques. The total regenerated cross-sectional area of the myelinated axons was similar in the repairs by fascicular tubulization to repairs by fascicular suture.
View details for Web of Science ID A1983RR52500007
View details for PubMedID 6316829
-
THE IRREPLACEABLE FREE FLAP .1. SKELETAL RECONSTRUCTION BY MICROVASCULAR FREE BONE TRANSFER
ANNALS OF PLASTIC SURGERY
1983; 10 (1): 36-42
View details for Web of Science ID A1983PY62700005
View details for PubMedID 6338797
-
CONSTRUCTION OF A RECTAL SPHINCTER USING THE ORIGIN OF THE GLUTEUS MAXIMUS MUSCLE
PLASTIC AND RECONSTRUCTIVE SURGERY
1982; 70 (1): 82-85
View details for Web of Science ID A1982NW05700017
View details for PubMedID 7089111
-
IRREPLACEABLE FREE FLAPS IN RECONSTRUCTIVE SURGERY .2.
ANNALS OF PLASTIC SURGERY
1982; 9 (6): 488-497
Abstract
Recent advances in myocutaneous flap and free-flap surgery can be combined to solve difficult reconstructive problems. The unreliability and difficulty of dissecting subcutaneous axial free flaps, as well as problems associated with the small size of their donor vessels, have been obviated by the newer free flaps. Although microvascular tissue transfer should not be employed when a more simple and reliable reconstruction technique is available, the capacity of these flaps to revascularize the recipient site, plus their ability to provide skin, muscle, and bone, has increased the indications for their use. We prefer the fascial sleeve approach to free-flap elevation compared with direct dissection of the vascular pedicle. The free flap has become an important technique for the reconstructive surgeon.
View details for Web of Science ID A1982PT30500007
View details for PubMedID 7165242
-
IRREPLACEABLE FREE FLAPS IN RECONSTRUCTIVE SURGERY .1.
ANNALS OF PLASTIC SURGERY
1982; 9 (6): 479-487
Abstract
Free flaps are increasingly being chosen to solve complex reconstruction problems. We describe a fascial sleeve approach to elevation of the donor flap which increases its safety and reliability. We report examples in which resultant revascularization of the recipient site causes the free flap to be irreplaceable for solving the particular clinical problem.
View details for Web of Science ID A1982PT30500006
View details for PubMedID 6299160
-
APPLICATION OF MAXILLOFACIAL INSTRUMENTS AND TECHNIQUES TO MANDIBULECTOMY AND MAXILLECTOMY
CLINICS IN PLASTIC SURGERY
1982; 9 (4): 541-548
View details for Web of Science ID A1982PP63100013
View details for PubMedID 7172599
-
A DYNAMIC MYOCUTANEOUS FLAP FOR HAND RECONSTRUCTION
JOURNAL OF HAND SURGERY-AMERICAN VOLUME
1980; 5 (6): 594-599
Abstract
Relocation of functional units by neurovascular pedicle transfer is firmly established in reconstructive hand surgery. Transfer of muscle and overlying skin, the myocutaneous flap, to provide skin cover is equally established. The dynamic myocutaneous flap is an extension of these concepts. Injection studies confirmed that the abductor digiti quinti muscle and its overlying hypothenar skin could be transferred on its neurovascular bundle. This dynamic myocutaneous flap was used to reconstruct both skin cover and functional opposition following resection of an arteriovenous malformation involving the thumb. Other clinical applications would include reconstruction of thenar skin and muscle lost secondary to electrical burns, avulsion, or tumor resection.
View details for Web of Science ID A1980KR83300016
View details for PubMedID 7430605
-
EFFECT OF LEVEL OF CORD INJURY ON PRESSURE ULCER DEVELOPMENT - REPLY
PLASTIC AND RECONSTRUCTIVE SURGERY
1980; 66 (2): 314–15
View details for DOI 10.1097/00006534-198008000-00036
View details for Web of Science ID A1980KB81100031
-
USE OF THE MEDIAL UPPER ARM SKIN AS AN ARTERIALIZED FLAP
HAND
1980; 12 (3): 241-247
Abstract
The skin on the underside of the upper arm is supplied in part by the superior ulnar collateral artery, a direct cutaneous artery arising from the brachial artery four to six cm distal to the pectoralis major insertion. Two-thirds to three-quarters of the length of the medial arm skin can be reliably transferred as an arterialized undelayed pedicle flap. This skin provides excellent coverage for the opposite hand from a relatively inconspicuous donor site. Transfer of this flap is safe and patient discomfort is minimal. It is recommended for elective reconstruction and emergency procedures.
View details for Web of Science ID A1980KQ39200004
View details for PubMedID 7439815
-
CHANGING PERSPECTIVES IN SURGICAL HAND REHABILITATION IN QUADRIPLEGIC PATIENTS
PLASTIC AND RECONSTRUCTIVE SURGERY
1979; 64 (4): 509-515
Abstract
Every motivated quadriplegic patient with resources for strong wrist extension, and lacking irreversible pathological features, is a candidate for reconstruction of at least a basic strong pinch. This basic pinch is better than that obtained with a prosthesis. We feel that this possibility exists in no less than 75 percent of our quadriplegic patients.
View details for Web of Science ID A1979HR89300011
View details for PubMedID 482437
-
MANAGEMENT OF PRESSURE SORES IN A SPECIALTY CENTER - REAPPRAISAL
PLASTIC AND RECONSTRUCTIVE SURGERY
1979; 64 (5): 683-691
Abstract
We report a study on the surgical management of 145 pressure sores in 115 patients treated in a spinal cord injury center. There is a definite trend toward better education of these patients, who do not develop their first pressure sores until years following the injury. When the patient comes in for an ulcer, he is usually healthy and the ulcer is small and clean. In such instances the ulcer can be excised and closed, preferably with a myocutaneous flap, and the patient can usually begin sitting by the 21st post-operative day. In the ideal setting he may be discharged to his home on a custom-fitted (for pressure) cushion within 4 to 5 weeks, without increasing the risk of recurrence. Prophylaxis for the future is, probably, the most essential part of the treatment.
View details for Web of Science ID A1979HW74900014
View details for PubMedID 388483
-
HERPETIC WHITLOW - NON-SURGICAL INFECTION OF HAND
PLASTIC AND RECONSTRUCTIVE SURGERY
1977; 60 (1): 125-127
Abstract
Herpetic whitlow, or herpes simplex infection of the fingertips, is a medical illness which responds unfavorably to surgical management. If left to its own course, this angry-appearing lesion will disappear with 3 to 4 weeks-with no residual damage.
View details for Web of Science ID A1977DP66600031
View details for PubMedID 20607955
-
COMMON HAND PROBLEMS
SURGICAL CLINICS OF NORTH AMERICA
1977; 57 (5): 1103-1132
Abstract
The principles illustrated in this brief survey are germane to all surgery. They cross whatever boundaries exist between specialties; in the hand, there are no divisions into parts for general, plastic, orthopedic, or neurosurgeons. They are essential to the success and parallel Boyes' description of Bunnell's influence in "the restoration of function, a careful detailed evaluation of the problem and a skillful manipulation of the parts, to accomplish the planned result. Solutions were sought and planned by thinking in broad terms of function, but the surgery is executed with maximum attention to details.
View details for Web of Science ID A1977DW76800018
View details for PubMedID 333631
-
USE OF VASTUS-LATERALIS MUSCLE FLAP FOR REPAIR OF TROCHANTERIC PRESSURE SORES
PLASTIC AND RECONSTRUCTIVE SURGERY
1977; 60 (3): 364-368
Abstract
The use of a vastus lateralis muscle flap is suggested as an approach to the surgical repair of trochanteric pressure sores in paraplegic patients. The details of the anatomy of the muscle are outlined, and our surgical technique for its use is described.
View details for Web of Science ID A1977DU18800006
View details for PubMedID 331366