ASRM - American Association for Hand Surgery

Transcription

PROGRAM BOOK
AAHS
ASPN
ASRM
ANNUAL SCIENTIFIC MEETINGS
Grand Wailea Resort
Jointly sponsored by:
Maui, Hawaii
January 7-13, 2009
RESORT MAP
TABLE OF CONTENTS
AAHS Board of Directors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
AAHS Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Hand Surgery Endowment Contributor List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
AAHS Historical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
ASPN Council Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
ASPN Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ASPN Historical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
ASRM Council Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
ASRM Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
ASRM Historical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Messages from the Program Chairs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
General Announcements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Networking Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2009 Exhibitor Listing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-18
CME Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19-21
Presenters’ Disclosure Listing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-23
Future Annual Meeting Locations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
AAHS Wednesday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Specialty Day Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Trauma Pre-Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
AAHS Thursday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Keynote Speaker: Daniel Gottlieb, PhD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
AAHS Friday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
J. Joseph Danyo Presidential Invited Lecturer: Louis L. Carter, Jr. MD, FACS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Comprehensive Hand Surgery Review Course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
AAHS/ASPN/ASRM Saturday Day-at-a-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
AAHS/ASPN/ASRM Presidents’ Invited Lecturer: Graham Gumley, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
ASPN Friday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Invited Speaker: Allan Belzberg, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
ASPN Saturday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Invited Speaker: Wyndell H. Merritt, MD, FACS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
ASPN Sunday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Invited Speaker: Lawrence J. Rossi Jr. MD, FAAP, DABMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
ASRM Saturday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
ASRM Master Series in Microsurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
ASRM Sunday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Presidents Invited Lecture: Thomas E. Starzl, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Godina Lecture: Michael Sauerbier, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
ASRM Monday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Buncke Lecture: Ralph Manktelow, MD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
ASRM Tuesday Day-At-A-Glance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Abstract Table of Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
2008-2009 AMERICAN ASSOCIATION FOR HAND SURGERY
BOARD OF DIRECTORS
President
President-Elect
Vice-President
Secretary
Treasurer
Historian
Parliamentarian
Scott H. Kozin, MD
Nicholas Vedder, MD
A. Lee Osterman, MD, FACS
Keith Brandt, MD
Mark Baratz, MD
Brian Adams, MD
Donald Lalonde, MD
Past Presidents
N. Bradly Meland, MD
Ronald Palmer, MD
Directors At Large
James Chang, MD
Eric Paul Hofmeister, MD
Steven McCabe, MD
Dean Sotereanos, MD
Affiliate Directors
Gretchen Kaiser-Bodell, OTD, MBA, OTR/L, CHT
Christine Novak, PT, MS, PhD(c)
Rebecca von der Heyde, MS, ORT/L, CHT
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AAHS COMMITTEES AND TASK FORCES
Please join us in thanking the following AAHS
committees and task forces who have helped
make the 2008 year successful.
BYLAWS COMMITTEE
Donald Lalonde, MD, Chair
Erika Lawler, MD
Michael Sauerbier, MD
Warren Schubert, MD
TECHNOLOGY COMMITTEE
George Landis, MD, Chair
H. Brent Bamberger, DO
Paul Brach, PT, MS, CHT
Coleen Gatley, PT, DPT, MS
Steven McCabe, MD
Jaiyoung Ryu, MD, FACS
EDUCATION COMMITTEE
Jaiyoung Ryu, MD, FACS, Chair
Timothy J. Best, MD, MSc, FRCSC
Jeffrey Budoff, MD
Paula Galaviz, OT
Kevin Plancher, MD
Aviva Wolff, BSc, OTR/L, CHT
VARGAS AWARD COMMITTEE
Maureen Hardy, PT MS, CHT, Co-Chair
Scott Kozin, MD, Co-Chair
Julianne Howell, PT, MS, CHT
Gretchen Kaiser-Bodell, OTD, MBA, OTR/L, CHT
Miguel A. Pirela-Cruz, MD
Rebecca von der Heyde, MS, OTR/L, CHT
FINANCE COMMITTEE
Mark Baratz, MD, Chair
Scott Kozin, MD
Jeffrey M. Palmer
Nicholas Vedder, MD
ASSETS ASSESSMENT TASK FORCE
Mark Baratz, MD, Chair
PRE-COURSE TASK FORCE
Miguel A. Pirela-Cruz, MD, Co-Chair
Jaiyoung Ryu, MD, FACS, Co-Chair
William C. Pederson, MD, Moderator
Randy Bindra, MD, Moderator
Rebecca Von Der Heyde, MS, OTR/L, CHT
MEMBERSHIP: ACTIVE COMMITTEE
Steven McCabe, MD, Chair
Kyle Bickel, MD, FACS
Keith Brandt, MD
Steven L. Moran, MD
Raj Sood, MD
HAND JOURNAL TASK FORCE
James Chang, MD, Chair
Mark Baratz, MD
Eric Paul Hofmeister, MD
Steven McCabe, MD
Dean Sotereanos, MD
Nicholas Vedder, MD
Elvin Zook, MD
MEMBERSHIP: AFFILIATE COMMITTEE
Rebecca von der Heyde, MS, OTR/L, CHT, Chair
Donna Breger Stanton, MA, OTR/L, CHT
Sharon Dest, PT, CHT
NOMINATING COMMITTEE
N. Bradly Meland, MD, Chair
Peter Amadio, MD
George Landis, MD
Nash Naam, MD
Robert Russell, MD
Aviva Wolf, BSc, OTR/L CHT
SOCIETY MISSION & GOALS TASK FORCE
A. Lee Osterman, MD, FACS, Chair
EDUCATION IN DEVELOPING/EMERGING COUNTRIES
OR DEVELOPING/EMERGING HAND SOCIETIES
TASK FORCE
Nash Naam, MD, Chair
PROGRAM COMMITTEE
Miguel Pirela-Cruz, MD, Chair
Randipsingh Bindra, MD, FRCS
Diana Carr, MD
Kevin Chung, MD
Gail Groth, OTR/L CHT MHS
M. Ather Mirza, MD
Jose Ortiz, MD
Mark Walsh, DPT, MS, CHT, ATC
THERAPIST ROLE IN AAHS ASSESSMENT TASK FORCE
Christine Novak, PT, MS, PhD(c), Chair
RESEARCH GRANTS COMMITTEE
Michael Neumeister, MD, Chair
Edward Athanasian, MD
Peter Evans, MD
Steve Moran, MD
David Netscher, MD
Jorge Orbay, MD
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Hand Surgery Endowment
2008 Contributor List
Joseph Agris, MD
Damon Anagnos, MD
Stephan Ariyan, MD
Kenneth Arthur, MD
John Attwood, MD
Alejandro Badia, MD
Nabil Barakat, MD
Mark Baratz, MD
Rocco Barbieri, MD
Kimberly Barrie, PT
Lynn Bassini, OTR, CHT
Andra Battocchio, LCDR, USPHS
John D. Bauer, MD
John Bax, MD, PhD
Matthew A. Bernstein, MD
Timothy J. Best, MD, MSc, FRCSC
David Bikoff, MD
Edward L. Birdsong, MD
Elizabeth Blake, Curtis
Phillip Blevins, MD
Keith E. Brandt, MD
Bruce Brewer, MD
Anthony Brown, MD
Mary Lynn Brown, MD
Robert Buckley, MD
Christine Burridge, PT, CHT
A. Lawrence Cervino, MD
Charles Chalekson,
Tyson Cobb, MD
J. Daniel, Labs, MD
Joseph Danyo, MD
Donald Ditmars, Jr., MD
Sam Dovelle, OTR
William Dzwierzynski, MD
Charles Eaton, MD
R. Evan, Crandall, MD
Martin Favetto, MD
David Fitz, MD
Richard Flaherty, MD
Richard S. Fox, MD
Paul Fragner, MD
Alan Freeland, MD
Randi Galli, MD
Jeffrey Garst, MD
Margaret Geringer, OTR
Robert J. Goitz, MD
Walter D. Gracia, MD
Neil Green, MD
John Grossman, MD
Amit Gupta, MD
Geoffrey Hallock, MD
Patrick Houvet, MD
Julianne Howell, PT, MS, CHT
Peter Innis, MD
Ronald Joseph, MD
esse Jupiter, MD
Ramasamy Kalimuthu, MD
Loree K. Kalliainen, MD, FACS
JAnn Kammien, PT, CHT
Martin Kassan, MD
Roger Khouri, MD
Jerome T. Landstrom, MD
W.P. Andrew Lee, MD
Mark Leslie, MD, FACS
JoAnne Levitan, MD
Paul Lim, MD
Mary Linda, Jurrisson, MD
Steven Macht, MD
Matthew M. Malerich, MD
John Mara, MD
D. Marshall, Jemison, MD
Howard Matsuba, MD
Steven McCabe, MD
Mehul Mehta, MD
N. Bradly, Meland, MD
Wyndell Merritt, MD
Susan Michlovitz, PT, PhD, CHT
Bruce A. Monaghan, MD
Jose Monsivais, MD
Carlos Montero, MD
Hiram Morgan, MD
Robert Morrow, MD, FACS
Nash Naam, MD
Daniel Nagle, MD
Ross Nathan, MD
Morgan E. Norris, MD
Kimberley O’Sullivan, MD, FACS
Edward Palmer, MD
Ronald Palmer, MD
Mukund Patel, MD, FACS
Joseph Perlman, MD
Kevin Plancher, MD
Subbarao Polineni, MD
Lorna E. Ramos, MA, OT
Norman Rappaport, MD, DDS
Kathleen Robertson, MD
Malcolm Roth, MD
Eric S. Rothenberg, MD, FACS
Robert Russell, MD
Miguel Saldana, MD
Robert Schenck, MD
Stephen Schnall, MD
Roger Simpson, MD
Martin Skie, MD
Norman Sogioka, MD
Somprasong Songcharoen, MD
Scott Steinmann, MD
Patrick Stewart, MD, FACS
William Swartz, MD
Jay S. Talsania, MD
Cary Tanner, MD
David Toivonen, MD
Thomas Tung, MD
Benjamin Van Raalte, MD
3
Thomas Tung, MD
Benjamin Van Raalte, MD
Nicholas Vedder, MD
Ann VonKersburg, PT, CHT
Eric E. Wegener, MD
Marwan A. Wehbe, MD
Larry Weinstein, MD
Arno Weiss, Jr., MD
Michael White, MD
Alan Wolf, MD
Tse-Shiung Wu, MD
George Wu, MD
Eric Wyble, MD
Levent Yalcin, MD
AAHS HISTORICAL INFORMATION
AAHS Past Presidents
J. Joseph Danyo, MD
Henry Burns, MD
Ray A. Elliott, Jr., MD
James Borden, MD
Kim K. Lie, MD
Frank L. Thorne, MD
Lawrence R. Werschky, MD
Robert T. Love, MD
Arnis Freiberg, MD
Thomas J. Krizek, MD
George L. Lucas, MD
Garry S. Brody, MD
James G. Hoehn, MD
Peter C. Linton, MD
Wallace H.J. Chang, MD
Austin D. Potenza, MD
Lee E. Edstrom, MD
C. Lin Puckett, MD
Robert J. Demuth, MD
Wyndell H. Merritt, MD
Frederick R. Heckler, MD
Robert D. Beckenbaugh, MD
David J. Smith, Jr., MD
James W. May, Jr., MD
Robert H. Brumfield, Jr., MD
Robert C. Russell, MD
Peter C. Amadio, MD
William M. Swartz, MD
William Blair, MD
Robert Buchanan, MD
Alan Freeland, MD
Allen Van Beek, MD
Richard Berger, MD
Susan Mackinnon, MD
Ronald Palmer, MD
1970-1972
1972-1973
1973-1974
1974-1975
1975-1976
1976-1977
1977-1978 deceased
1978-1979
1979-1980
1980-1981
1981-1982
1982-1983
1983-1984
1984-1985
1985-1986
1986-1987
1987-1988
1988-1989
1989-1990
1990-1991
1991-1992
1992-1993
1993-1995
1995-1996
1996-1997
1997-1998
1998-1999
1999-2000
2000-2001
2001-2002
2002-2003
2003-2004
2004-2005
2005-2006
2006-2007
2007-2008
Presidential Invited Lecturers
Harold E. Kleinert, MD
Arthur C. Rettig, MD
Paul W. Brand, MD
Ronald L. Linschied, MD
Guy Foucher, MD
Michael R. Harrison, MD
Dallas D. Raines
John Texter, MD
Vincent R. Hentz, MD
Nancy Dickey, MD
Michael Wood, MD
Francisco Rosas
Arnold-Peter Weiss, MD
Susan Mackinnon, MD
1989
1990
1991
1993
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
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Elvin Zook, MD
Gavin Menzies
Peter Amadio, MD
Robert Beckenbaugh, MD
Allen Van Beek, MD
2004
2005
2006
2007
2008
Keynote Speakers
William L. White, MD
John W. Madden, MD
J. William Littler, MD
Clifford C. Snyder, MD
Robert A. Chase, MD
Richard J. Smith, MD
James M. Hunter, MD
Bernard McC. O’Brien, MD
Erle E. Peacock, Jr., MD
Michael Jabelay, MD
Robert M. McFarlane, MD
James H. Dobyns, MD
Adrian E. Flatt, MD
John B. Carlson, PhD
Pat Clyne
David M. Evans, FRCS
Eugene Nelson, MD
Fritz Klein
Janet L.Babb
Frank E. Jones, MD
Joseph Buckwalter, MD
Linda Cendales, MD
Arnold-Peter Weiss, MD
Terry L. Whipple, MD, FACS
Jeff Lictman, MD, PhD
Richard Kogan, MD
Bob Jamieson
Ramez Naam
1978
1979
1980
1981
1982
1983
1984
1985
1986
1988
1989
1990
1991
1992
1993
1995
1996
1997
1998
1999
2000
2001
2002
2003
2005
2006
2007
2007
2008
Clinician/Teacher of the Year
Forst Brown, MD
James Hoehn, MD
Alan Freeland, MD
Wyndell Merritt, MD
Peteramadio, MD
Anthony DeSantolo, MD
Michael Jabaley, MD
Maureen Hardy, PT, MS, CHT
Sterling Mutz, MD
Sue Michlovitz, PT, PhD, CHT
Richard E. Brown, MD
Nash Naam, MD
Miguel Saldana, MD
1995
1996
1997
1998
1999
2000
2002
2002
2002
2002
2003
2003
2004
2007
2008-2009 AMERICAN SOCIETY FOR PERIPHERAL NERVE
COUNCIL
President
President-Elect
Vice President
Secretary
Treasurer
Historian
Immediate Past President
Past President
Howard M. Clarke, MD, PhD
Paul S. Cederna, MD
Ivica Ducic, MD, PhD
Robert Spinner, MD
Thomass H.H. Tung, MD
Gregory R.D. Evans, MD, FACS
Rajiv Midha, MD
Council Members at Large
Loree K. Kalliainen, MD
Gedge D. Rosson, MD
Jonathan M. Winograd, MD
5
ASPN COMMITTEES
Please join us in thanking the following ASPN
committees who have helped make the 2008
year successful.
Newsletter Committee
Nash Naam, MD, Editor
Randip R. Bindra, MD, FRCS
A. Lee Dellon, MD
Michael W. Neumeister, MD
Robert C. Russell, MD, Ex-Officio
Bylaws Committee
Warren Schubert, MD, Chair
Paul S. Cederna, MD
William Kuzon, Jr., MD
Warren Schubert, MD
Robert C. Russell, MD Ex-Officio
Nominating Committee
Gregory R.D. Evans, MD, FACS, Chair
Allan J. Belzberg, MD
Christine Novak, PT, MS
Robert Tiel, MD
Thomas H. H. Tung, MD
Rajiv Midha, MD, Ex-Officio
Coding and Reimbursement Committee
Keith E. Brandt, MD, Chair
Terence M. Myckatyn, MD
Gedge D. Rosson, MD
Education Committee
William Kuzon, MD, Chair
Loree K. Kallianinen, MD
William A. Zamboni, MD
Program Committee
Nash Naam, MD, Chair
David L. Brown, MD, FACS
Gregory M. Buncke, MD
David T.W. Chiu, MD
Matijn I.A. Malessy, PhD
Warren Schubert, MD
Robert C. Russell, Ex-Officio
Finance Committee
Paul S. Cederna, MD, Chair
Jonathan E. Isaacs, MD
Bradon J. Wilhelmi, MD
Robert Spinner, MD, Ex-Officio
Time and Place Committee
Paul S. Cederna, MD, PhD, Chair
Howard M. Clarke, MD
Gregory R. D. Evans, MD, FACS
Loree K. Kalliainen, MD
Rajiv Midha, MD
Gedge D. Rosson, MD
Robert Spinner, MD
Thomas H. H. Tung, MD
Grant Generating Committee
Robert Spinner, MD, Chair
A. Lee Dellon, MD
Gregory R.D. Evans, MD, FACS
Rajiv Midha, MD, Ex-Officio
Membership Committee
Howard M. Clarke, MD, PhD, Chair
Tessa Gordon, PhD
Warren C. Hammert, DDS, MD
Website Committee
Paul S. Cederna, MD, Chair
Keith E. Brandt, MD
Ranjan Gupta, MD
6
ASPN HISTORICAL INFORMATION
Founding Council
Established April 19, 1990
Warren Breidenbach, MD
Thomas Brushart, MD
David Chiu, MD
A. Lee Dellon, MD
Richard Ehrlichman, MD
Nelson Goldberg, MD
Roger Khouri, MD
Howard Klein, MD
Susan Mackinnon, MD
Hallene Maragh, MD
Wyndell Merritt, MD
Michael Orgel, MD
Elliot Rose, MD
Joseph Rosen, MD
Brooke Seckel, MD
Saleh Shenaq, MD
Thomas Stevenson, MD
Berish Strauch, MD
Julia K.Terzis, MD, PhD
Allen Van Beek, MD
Bruce Williams, MD
ASPN Past Presidents
Julia K. Terzis, MD, PhD
A. Lee Dellon, MD
Berish Strauch, MD
H. Bruce Williams, MD
Susan E. Mackinnon, MD
Wyndell Merritt, MD
Allen Van Beek, MD
Saleh Shenaq, MD
David T. W. Chiu, MD
Nancy H. McKee, MD
William M. Kuzon, Jr., MD, PhD
Keith E. Brandt, MD
Steven McCabe, MD
Maria Siemionow, MD, PhD
Rajiv Midha, MD
Gregory R. D. Evans, MD, FACS
1990-1992
1992-1993
1993-1994
1994-1995
1995-1996
1996-1997
1997-1998
1998-1999
1999-2001
2001-2002
2002-2003
2003-2004
2004-2005
2005-2006
2006-2007
2007-2008
7
2008-2009 AMERICAN SOCIETY FOR
RECONSTRUCTIVE MICROSURGERY
EXECUTIVE COUNCIL MEMBERS
President
President-Elect
Vice-President
Secretary
Treasurer
Treasurer-Elect
Immediate Past President
Neil F. Jones, MD
Peter C. Neligan, MD
Joseph M. Serletti, MD, FACS
Allen T. Bishop, MD
Lawrence B. Colen, MD
Senior Members-At-Large
Geoffrey L. Robb, MD
Michael R. Zenn, MD
Junior Members-At-Large
Elisabeth K. Beahm, MD
Michael Klebuc, MD
Historian
David Chang, MD
8
ASRM COMMITTEES
Please join us in thanking the following ASRM
committees who have helped make the 2008
year successful.
Ad Hoc Micro Fellowship
Charles E. Butler, MD, Chair
Gregory Buncke, MD
Joseph Disa, MD
Peter Neligan, MD
Joseph Serletti, MD
William Zamboni, MD
Finance Committee
William Zamboni, MD, Chair
Allen T. Bishop, Treasurer
Geoffrey Robb, MD
Joseph M. Serletti, MD, FACS, Ex-Officio
Godina Fellowship Selection Committee
Raymond Dunn, MD
Neil F. Jones, MD
Peirong Yu, MD
Zoran M. Arnez, MD
Audit Committee
David Chang, MD, Chair
Joseph Disa, MD
Raymond Dunn, MD
Master Series Symposium
Lawrence Gottlieb, MD, Chair
Bylaws Committee
Elisabeth Beahm, MD, Chair
Anthony Smith, MD
Membership Committee
Charles Butler, MD
David Low, MD
Robert Whitfield, MD
Michael Zenn, MD
Peter Neligan, MD, Ex-Officio
Clinical Guidelines & Outcomes Committee
Raymond Dunn, MD, Chair
James Higgins, MD
Howard N. Langstein, MD
Nominating Committee
Lawrence B. Colen, MD, Chair
Elisabeth Beahm, MD
Gregory Buncke, MD
Gregory R.D Evans, MD, FACS
Peirong Yu, MD
CPT/RUC Committee
Raymond M. Dunn, MD, Chair
Daniel J. Nagle, MD
William C. Pederson, MD
Michael R. Zenn, MD
Keith Brandt, MD, Ex-Officio
Program Committee
J. Brian Boyd, MD, FRCS, Chair
Robert Allen, MD
David Chang, MD
Peter Cordiero, MD
R. Jobe Fix, MD
James Higgins, MD
Steve Moran, MD
Maria Siemionow, MD, PhD
Guenter Germann, MD, Ex-Officio
Education Committee
William Kuzon,MD, PhD, Chair
Maurice Nahabedian, MD
Maria Siemionow, MD, Ph.D
Peirong Yu, MD
Technical Exhibits Committee
Randall Culp, MD, Chair
L. Scott Levin, MD, FACS
Eduardo Rodriguez, DDS, MD
Electronic Communications Committee
Michael Miller, MD, Chair
Howard N. Langstein, MD
Peter Murray, MD
Charles E. Butler, MD, Ex-Officio
Time & Place Committee
Lawrence B Colen, MD, Chair
William Pederson, MD
Endowment Committee
Robert L. Walton, MD, FACS, Chair
Keith E. Brandt, MD
Joseph Disa, MD
9
ASRM HISTORICAL INFORMATION
1983 Founding Council
James B. Steichen, MD, Berish Strauch, MD, Julia K. Terzis, MD, James R. Urbaniak, MD, Allen L. Van Beek, MD
Year
President
Annual Meeting Site
Founders/Godina/Buncke Lecturers
1985
1986
1987
1988
1989
1990
1991
1992
1993
Berish Strauch, MD
James R. Urbaniak, MD
Joseph E. Kutz, MD
James B. Steichen, MD
Allen L. Van Beek, MD
Michael B. Wood, MD
Andrew J. Weiland, MD
Graham Lister, MD
Las Vegas, NV
New Orleans, LA
San Antonio, TX
Baltimore, MD
Seattle, WA
Toronto, Ontario, Canada
Orlando, FL
Scottsdale, AZ
Kansas City, MO
1994-95
Marco Island, FL
1995-96
Ralph T. Manktelow, MD
Tucson, AZ
1996-97
James A. Nunley, MD
Boca Raton, FL
1997-98
William M. Swartz, MD
Scottsdale, AZ
1998-99
David T. W. Chiu, MD
Waikoloa, HI
1999-2000
Daniel Nagle, MD
Miami, FL
2000-2001
Saleh M. Shenaq, MD
San Diego, CA
2001-2002
Randy Sherman, MD
Cancun, Mexico
2002-2003
Julia K. Terzis, MD, PhD
Kauai, HI
2003-2004
Ronald M. Zuker, MD
Palm Springs, CA
2004-2005
Robert L. Walton, MD, FACS
Fajardo, Puerto Rico
2005-2006
Tucson, AZ
Henry J. Buncke, MD
Robert D. Acland, MD
Berish Strauch, MD
G. Ian Taylor, FRCS, FRACS
Andrew Lightbody
Alain Gilbert, MD
Edgar Biemer, MD
Algimantas Narakas
Nguyen Huy Phan, MD
Mark A. Schusterman, MD
Fu Chan Wei, MD
Randy Sherman, MD
James R. Urbaniak, MD
Zoran M. Arnez, MD
L. Scott Levin, MD
Julia K. Terzis, MD
Phillip Blondeel, MD
Allen Van Beek, MD
Gregory R. D. Evans, MD
Wayne Morrision, MD, FRACS
Roger Khouri, MD
Robert Russell, MD
William Zamboni, MD
Panayotis Soucacos, MD
Raymond Dunn, MD
Ralph Manktelow, MD
Milomir Ninkovic, MD, PhD
Isao Koshima, MD
Michael Neumeister, MD, FRCSC, FACS
G. Ian Taylor, MD, FACS
David Chang, MD, FACS
Fu Chan Wei, MD, FACS
Founders’ Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Godina Lecturer
Buncke Lecturer
Godina Lecturer
Buncke Lecturer
2006-2007
Rio Grande, Puerto Rico
2007-2008
Beverly Hills, CA
Ming Huei Cheng, MD, MHA
James Urbaniak, MD
Peirong Yu, MD
Berish Strauch, MD
Godina Lecturer
Buncke Lecturer
Godina Lecturer
Buncke Lecturer
10
MESSAGES FROM THE PROGRAM CHAIRS
AAHS
Aloha. In the tradition of American Association for Hand Surgery (AAHS), the 2009 meeting promises to have a healthy mixture of education and relaxation at the Grand Wailea Resort on the beautiful island of
Maui, Hawaii. The sunny beaches and warm weather provide a beautiful backdrop for our meeting in conjunction with the American Society for Peripheral Nerve (ASPN) & the American Society for Reconstructive
Microsurgery (ASRM). The Annual Meeting will offer a variety of scientific paper presentations, educational panels, instructional courses and workshops for the practicing Hand Surgeon to enhance his or her knowledge in a beautiful venue.
The Specialty Day Program organized by Rebecca Von der Heyde, MS, OTR/L, CHT TR/L will occur on Wednesday. The focus is Complex Trauma and Management. The topics are germane to all Hand Surgeons
and Therapists and include Traumatic amputations, Splinting and Motion following Replantation Surgery, To Salvage or Not to Salvage, Nerve Transfers and Case Presentations. On Wednesday, there will also
be a pre-course on Trauma geared toward surgeons and provocative topics that will challenge your thinking and management of many clinical problems. The theme will be “Standard of Care or Stretching the
Indications.” Controversy regarding indications for fixation of scaphoid fractures, clavicle fractures and radial head fractures will be discussed. Similarly, indications and techniques for scapholunate ligament repair,
tendon repair, and nerve reconstruction will be highlighted. The Trauma pre-course will be moderated by William C. Pederson, MD and Randy Bindra, MD who have recruited an all-star line up. Attendees will
gather Wednesday evening for cocktails and spectacular sunset views during the annual Welcome Reception.
Thursday morning will start early with our Instructional Courses, a panel on “Minimally Invasive Fracture Fixation—How I Do It!” followed by our Scientific Paper Sessions, Presidential address and Keynote Speaker
Dan Gottlieb, MD. Dr. Gottlieb is a Psychologist from Philadelphia and a radio host and author. His show Voices in the Family was first aired in 1985 on Philadelphia’s NPR affiliate. From the onset, Dr. Gottlieb’s
relationship with his audience was described as “magical.” In 1979, while preparing a surprise for his wife on their 10th anniversary, Dr. Gottlieb was in a near-fatal automobile accident, which left him quadriplegic. Since then, he has faced depression, divorce and the death of his wife, sister and parents. Throughout all, he maintained his devotion to family and his career. Now, he sits in a wheelchair observing life
and gaining unusual insight into what it means to be human. He will discuss what makes us human and what makes us happy. A book signing will follow his presentation. In the afternoon, the program will offer
additional instructional courses and industry sponsored workshops, which will provide hands-on learning in a safe setting.
Friday, there will be a focus on reconstruction and humanitarian missions with Louis L. Carter, MD our Joseph Danyo Invited Speaker. Dr. Carter is an active member of the AAHS, but spends the majority of his
time volunteering at Tenwek Hospital in western Kenya. His talk will be revealing and insightful. Friday will also have “An Update on Nerve Reconstruction” Panel and the popular Comprehensive Hand Surgery
Review Course, chaired by Steven L. Moran, MD. Friday’s evening social function will have Maui’s most popular band Jimmy Mac & The Kool Kats. This event will offer attendees the opportunity to network and
socialize in a casual fun environment.
Saturday, the learning continues with our combined societies (AAHS/ASPN/ASRM). Instructional courses and panels on “Crisis In Hand Trauma Coverage” led by L. Scott Levin, MD and “Medical Diplomacy” with moderators Eric Hofmeister, MD and Miguel Pirela-Cruz, MD will help us review our mission in Hand Surgery. The program is topped by our combined AAHS/ASPN/ASRM invited lecturer Graham Grumley, MD.
Dr. Grumley has spent considerable time volunteering in Phnom Penh, Cambodia as well as Delhi, India. This day finishes with a Golf Tournament and the ASPN/ASRM Cocktail Reception with a strict “no-tie” zone.
Welcome to Maui!
Mahalo,
ASPN
Miguel A. Pirela-Cruz, MD, FACS
AAHS Program Chairperson
Welcome to Paradise!!
Welcome to Maui with its lush exquisite beauty, its deep blue waters and its white sandy beaches. Welcome to the fine weather and the rainbows. Welcome to the natural beauty that is the best of what Mother
Nature can offer. And welcome to the 18th Annual Meeting of the American Society for Peripheral Nerve. The meeting will be held on Friday, Saturday and Sunday, January 9th, 10th and 11th, 2009 at the
beautiful Grand Wailea Resort & Spa. In the midst of this symphony of colors, shapes and forms, this year’s scientific meeting promises to be as exciting and as enjoyable as the natural beauty of Maui.
The theme of this year’s meeting is “Pain”; which has been for a long time a myth and mystery. We are still grappling with understanding the nature of pain and we are struggling with managing our patients
with chronic pain. There will be lectures, instructional courses and panel discussions regarding pain including basic science and clinic management. There will be also presentations on some non-traditional
methods of pain management such as Acupuncture.
The program will start at noon on Friday. Our first invited speaker is Dr. Allan Belzberg who will talk about Neuropathic Pain: From Beneath to Bedside and Back Again. This will be followed by a panel
discussion chaired by Wyndell Merritt, M.D, about Chronic Pain Management. We are honored that Dr. Andrew Koman, President of the American Society for Surgery of the Hand will be a member of this
panel to share with us his approach to chronic pain management. Saturday morning will be a combined session with the American Association for Hand Surgery and American Society for Reconstructive
Microsurgery. In one of the instructional courses on that day, Dr. Greg Dumanian will share with us his experience of innervation of Multiple Nerve Transfers for Control of Upper Extremity Myoelectric Prostheses
(Targeted Reinnervation); which is a very exciting innovation. Dr. Larry Rossi will discuss the principles and applications of acupuncture. On Saturday afternoon, Dr. Wyndell Merritt, our invited speaker will
talk about his experience with Chronic Regional Pain Syndrome.
On Sunday, there will be six instructional courses discussing topics of Headache, Neuroma Management, CRPS, Tissue Engineering for Peripheral Nerves, Denervation Techniques for Painful Musculoskeletal
Conditions and Nerve Transfers. There will be also a combined panel with the ASRM that will be moderated by our President Dr. Bob Russell about Failed Carpal and Cubital Tunnel Surgeries. The panel will
include Drs. Neil Jones, Susan Mackinnon and Allen van Beek. Dr. Larry Rossi, the invited speaker will discuss the History of Acupuncture and its use in Management of Chronic Pain.
Again, welcome to beautiful Maui. I am looking forward to seeing you and I hope that the program will be exciting and stimulating and enjoyable to all of us.
ASRM
Nash Naam, MD
ASPN Program Chairperson
Once again the American Society for Reconstructive Microsurgery’s annual meeting convenes in the magnificent Hawaiian Islands – this time at the famous Grand Wailea Resort in Maui.
For many attendees, the lush vegetation, sunny weather, vibrant colors and amazingly hospitable people provides an idyllic break from frosted leafless trees, frozen winds, looming gray skies and slushy urban
streets. For others, the contrast may be less dramatic but the change equally welcome. Few will find the Grand Wailea wanting in terms of personal luxury, fine dining, recreational facilities and scenic beauty. It is a veritable oasis within an oasis: a place where members of the ASRM, its sister societies and honored guests from around the world will meet socially - as well as professionally - in a relaxed and cordial environment.
The theme for this year’s meeting is the 25th ‘Silver’ anniversary of the Society. Special celebrations are planned. Cognizant of the fact that many of the participants would like to don their baggies, ‘hang five,’
and head for the ‘green room,’ the symposium will end early each day to permit recreational activities. For this purpose, the number of major panels has been reduced: but those that remain will update the
registrants in all the major areas of microsurgery. In addition, the instructional courses have been increased in number and converted into ‘mini panels.’ Up to six of these will run simultaneously. Each will have
a moderator with three to five panelists, and a wide range of topics will allow registrants to customize their experience according to their interests. Conjoint panels with the AAHS and ASPN are also planned.
The Masters’ Symposium will present: ‘Disasters of the Masters’ – an expert collage of what not to do in Microsurgery and how to deal with the consequences. Once more, the ever popular ‘Best Save/Best
Case’ feature has been retained and a prize will be given to the presenter of the most dramatic microsurgical rescue. Most importantly, to accommodate a record number of original papers submitted for presentation, there will be an expanded timetable with simultaneous sessions on non-conflicting topics. Original presentations, both basic science and clinical, are vital to maintain the dynamism of Microsurgery
and many excellent papers that do not fit into the formal program will be available as poster presentations.
Undoubtedly, the intellectual experience will be unique, but the symposium’s idyllic locale will set the stage for renewing old friendships, enjoying scenes of immense beauty, and participating in world class
recreation.
Welcome to Maui!
J. Brian Boyd, MD
ASRM Program Chairperson
11
GENERAL ANNOUNCEMENTS
Meeting Service Hours
Tuesday, January 6
Wednesday, January 7
Thursday, January 8
Friday, January 9
Saturday, January 10
Sunday, January 11
Monday, January 12
Tuesday, January 13
(subject to change)
3:00pm – 7:00pm
6:30am – 5:00pm
6:30am – 4:30pm
6:30am – 6:00pm
6:30am – 5:00pm
6:30am – 2:30pm
6:30am – 4:00pm
6:30am – 3:00pm
AAHS Poster Viewing Hours
The AAHS Poster Presentations will be placed in the Haleakala Ballroom Foyer. Posters will be available for viewing Wednesday, January 7th Friday January 9th. If you are a presenter, please have your posters set up prior to 5:00pm on Wednesday and taken down prior to 12:00pm on
Friday. The American Association for Hand Surgery will not be responsible for any poster that is not removed within the time allotted.
ASPN Poster Viewing Hours
The ASPN Poster Presentations will be placed in the Haleakala Ballroom Foyer. Posters will be available for viewing Friday, January 9th Sunday, January 11th. If you are a presenter, please have your posters set up prior to 1:00pm on Friday and taken down prior to 2:00pm on
Sunday. The American Society for Peripheral Nerve will not be responsible for any poster that is not removed within the time allotted.
ASRM Digital Poster Viewing Hours
The ASRM Poster Presentations will be available for viewing in the Silversword Room from Saturday, January 10th - Tuesday, January 13th.
Commercial Exhibits
The commercial exhibits will be located in Haleakala Gardens. A variety of commercial exhibits are featured at the meeting, enabling the
attendees to learn about the technological advances pertaining to upper extremity surgery, neurosurgery and reconstructive microsurgery, and
to meet key suppliers. Please refer to the Exhibit Listing in this book.
Exhibit Hours
Friday, January 9
Sunday, January 11
7:00am – 6:00pm
7:45am – 3:00pm
6:30am – 3:00pm
Speaker Ready Room Hours
The Speaker Ready Room will be located in the Silversword Room.
Wednesday, January 7
Thursday, January 8
Friday, January 9
Sunday, January 11
Monday, January 12
Tuesday, January 13
6:00am – 5:00pm
6:30am – 3:30pm
6:00am – 5:00pm
6:00am – 4:00pm
6:30am – 2:30pm
6:30am – 2:30pm
6:30am – 4:30pm
Dress Code
We encourage meeting attendees to dress casually and comfortably. Jackets and ties are not required for any business or networking events. If
you plan to be outdoors in the evening, a jacket may be preferred.
Message Board
A message board will be set up near Meeting Services in the Haleakala Ballroom Foyer. Please refer to the message board for meeting
notices and general announcements.
Internet Center
Will be available to check email and download boarding passes located in the Haleakala Gardens.
12
NETWORKING EVENTS
Networking events are offered to promote collaboration in a social environment, and to enhance your meeting experience. Many of the events are included in your
registration fee, and we encourage you to purchase tickets for your guests for all networking events. Attendee name badge or a guest ticket is required for all social
events.
AAHS Hand Therapist Reception: Wednesday, January 7: 5:00pm - 6:00pm Cost: Complimentary to AAHS Hand Therapist Attendees
Additional tickets not available.
The inclusive nature of AAHS has attracted therapists and maintained their loyalty over many years. AAHS Therapist attendees are welcomed by Dr. Scott Kozin, AAHS
President, for a cocktail reception upon completion of specialty day programming. This event is indoor and outdoor, please dress accordingly.
AAHS Welcome Reception: Wednesday, January 7: 6:00pm – 8:00pm Cost: 1 ticket included in AAHS registration.
Additional tickets available @ $50 each; tickets for children and young adults ages 5 - 20 available @ $25 each.
Reconnect and reflect with fellow meeting-goers at the gorgeous Grand Dining Room and Terrace overlooking the horizon of the Pacific Ocean. This event is indoor
and outdoor, please dress accordingly. Tickets include hosted beverages and light hors d’oeuvres.
AAHS Awards Dinner Dance: Concert In The Park: Friday, January 9: 7:00pm – 10:00pm Cost: 1 ticket included in AAHS registration.
Additional adult tickets available @ $125 each; tickets for children and young adults ages 5 - 20 available @ $55 each.
After we congratulate award winners, Jimmy Mac and the Kool Kats will rock the park during this open air concert and dance party on the resort’s
lawn. From funk to Motown, Buffet to the Beach Boys, disco to swing, and just a lot of good old rock & roll, this band has something for everyone. Dress
accordingly for barefoot dancing. Ticket includes casual buffet dinner, hosted beverages and hours of entertainment.
AAHS/ASRM 13th Annual Day At The Links: Saturday, January 10: Tee times: 12:00pm – 1:15pm Cost: $230 per player. Tickets
are non-refundable.
Nike Rental Clubs: $53 / must be arranged in advance to guarantee availability.
Another memorable golf experience unfolds on the first class Gold Course at the Wailea Country Club. This year’s format is a Shamble, and
promises a challenge. Each member of your foursome hits a tee shot. The best drive of the team is selected, and all players play their own ball
out from that point. Due to course restrictions, the tournament will be scheduled as consecutive tee times, allowing you the flexibility to sign up for
your preferred tee time and foursome. We’re looking forward to seeing you on tournament day, and will pass on more detail and instructions in
your welcome packet. Greens fee, lunch, transportation and golf course gratuities included.
ASPN/ASRM Welcome Reception: Saturday, January 10: 6:00pm – 8:00pm Cost: 1 ticket included in ASPN and ASRM registration.
Additional tickets available @ $50 each; tickets for children and young adults ages 5 - 20 available @ $25 each.
Join ASPN and ASRM at the shoreline of the Pacific Ocean at the resort’s Molokini Garden Lawn and treat yourself to a spectacular Maui sunset.
This event is outdoor on a grassy lawn so dress accordingly. Tickets include beverages and light hors d’oeuvres. Michael Kollwitz is one of the 'first
generation' of Chapman Stick players and will be performing this evening. The Chapman Stick® is easily the most radical innovation in stringed
instruments since the invention of the electric guitar
The ASPN & ASRM would like to thank ASSI for their generous support of this reception.
ASRM 25th “Silver” Anniversary Celebration: Monday, January 12: 6:30pm – 10:00pm Cost: 1 ticket included in ASRM
registration.
Additional tickets available @ $125 each; tickets for children and young adults ages 5 - 20 @ $55 each.
Tonight we’ll celebrate 25 years of our finest achievements under the glow of a full moon and a star-studded sky. Commemorate this special
evening with us by dancing the night away on the expansive grounds of the Grand Wailea Resort. Cocktail attire appropriate. This event is
outdoors on a grassy lawn, so please plan accordingly. Ticket includes hors d’oeuvres, dinner, beverages and entertainment.
ASRM Guest Fee
Have your guest or spouse join you for ASRM social events, breakfasts and lunches during the official dates of the ASRM meeting (Saturday – Tuesday) at a reduced
price. Please see ASRM daily schedules for details. ASRM guests will not receive CME credit. Any attendee that plans to attend general sessions and receive CME credit must be a healthcare professional and register as a regular attendee. Cost $250 per additional guest.
OPTIONAL TOURS AND ACTIVITIES
The concierges of the Grand Wailea’s Tour Desk offer a wide variety of organized tours, as well as daily youth and adult activities that take place at the resort (for
resort guests only.) When you arrive, you’ll have an opportunity to visit with the concierge to plan the activities of your choice. Plan ahead and visit grandwailearesort.com, or call the concierge at 800-888-6100 #8 to learn more about the many possibilities. If you prefer to join in with fellow association members, we’ve made
special arrangements for a few private tours that can be reserved in advance. On-site ticket purchases will be limited, and some tours may be unavailable. If tour
ticket minimum sales are not met, some tours may be cancelled. In these cases, all advance reservation payments will be fully refunded.
Sunset Sensation Catamaran Sail: Offered: Friday, January 9 from 4:00pm – 7:00pm Cost: Adult Ticket $85; Child 2 – 12 $64; children under 2 free
Relaxing and watching fabulous sunsets from the Kai Kanani is one of Maui’s favorite pastimes. On this sail, you’ll toast the good things in life with family and friends
as you casually cruise the Pacific Ocean aboard the sleek Kai Kanai catamaran. The trip departs from the beach of the Maui Prince Resort, approximately 10 minutes
from the Grand Wailea Resort. You’ll enjoy scenic views of South Maui, Molokini & Kahoolawe. Dress casually in beach shoes and shorts or roll up pants, as you’ll
wade into shallow water to board. Having a light cover up is helpful too. Barefoot and fancy free, you’ll find a comfy spot on the catamaran to watch a spectacular
sunset. Visit kaikanani.com for more information. Included: Round-trip transportation via group taxi transfers, freshly prepared hot and cold Pupu’s (appetizers), full
hosted bar, champagne, two hour sail, gratuities and tax.
Snorkel Sail and Whale Watching: Offered: Saturday, January 10 from 12:15pm – 5:45pm Cost: Adult Ticket $80; Child 3 – 12 $65; children under 3 free
Board the Four Winds II at the Maalaea Harbor, a 55 foot glass-bottom catamaran for this tropical adventure. Sail and motor your way to Molikini or the Coral Gardens
(the tradewinds will dictate the destination that day) with a crew that is completely dedicated to your needs. Enjoy whale watching, snorkeling and sport fishing (all gear
included), waterslide, sunbathing, swimming, boogie boards and much more. This trip is a must-do for families and it offers something for all ages. From the avid snorkeler to those that don’t swim, the Four Winds II accommodates everyone and provides a whole lot of fun on-deck or in the water. Visit mauicharters.com for more information. Included: Round-trip transportation, BBQ lunch, beer, wine and soda, marine naturalist, all snorkel gear and instruction, sport fishing, waterslide, glass-bottom
viewing, two spacious decks, see-boards (large boogie board equipped with a Plexiglas view port), free use of optical masks and a fresh water shower. Optional:
SNUBA Diving for $50. It’s just like SCUBA without tanks or heavy gear, and no certification or experience is necessary (purchase day of.)
Honuaula Luau at The Wailea Beach Marriott Resort: Offered every Monday, Thursday, Friday & Saturday Evenings from 5:00pm - 8:30pm Prices
range from $15 for children under 6, to $104 for adult premium seating
Travel back to a time when the mighty seafaring Polynesians discovered the land of Hawaii during this entertaining evening. Performances touch upon the documented voyages of La’amaikahiki and Moikeha who first came to this sacred island called Maui and speaks of gods and goddesses that watched over the courageous
people who co-existed in harmony. This story, combined with other traditional stories, create an exciting evening of traditional chant and hula. Dancing, family activities, Hawaiian arts and crafts and entertainment all take place from 5:00 pm – 8:00 pm. A lavish buffet dinner is served at 6:00 pm. Located Ocean Front at the
Wailea Beach Marriott Resort & Spa, 3700 Wailea Alanui Drive, Waliea Hawaii 96753, a 10 minute walk from the Grand Wailea Resort, or a 2 minute taxi ride.
Contact the Marriott directly to make advance reservations at honuaula-luau.com or 808. 875.7710.
13
2009 EXHIBITOR LISTING
Accutome
Booth: 34
Brian Chandler
ASSI
Booth: 21
Marie Bonazinga
3222 Phoenixville Pike
Malvern, PA 19355
toll-free 800-979-2020
phone 610-889-0200
fax 610-889-3233
300 Shames Drive
Westbury, NY 11590
phone 800-645-3569
fax 516-997-4948
email: assi@accuratesurgical.com
www.accuratesurgical.com
email: bchandler@accutome.com
www.accutome.com
ASSI will feature the Engler Breast Retractor, the Stanger C Breast Retractors
and the new Lalonde Breast Sizers, the Lalonde Percutaneous Bone Clamp
with K-wire guide, Face Lift Retractors, Campbell Lip Awl, Matarasso Lipo
Roller and SuperCut Face Lift Scissors, ASSI’s Bipolar Scissors, Micro
Monopolar Forceps, the Surex Sural Nerve Extractor and Nerve
Holding/Cutting Forceps. ASSI’s Hand Crafted Microsurgical Instruments and
Clinical Microvascular Clamps.
Accutome is an industry leader in handheld surgical instruments, including diamond and disposable steel knives. Accutome also carries a full line of sutures.
Accutome repairs handheld surgical instruments and diamond knives.
American Society of Plastic Surgeons
Booth:38
Anne Footle
Auxilium Pharmaceuticals
Booth: 28
Joyce Homewood
American Society of Plastic Surgery
444 East Algonquian Road
Arlington Heights, IL 60005
phone 847-228-9900
fax 847-981-5482
40 Valley Stream Parkway
Malvern, PA 19355
phone: 484-321-5900
fax: 484-321-2258
email: ejm@plasticsurgery.org
www.plasticsurgery.org
The American Society of Plastic Surgeons is the largest organization of boardcertified plastic surgeons in the world. With 6,000 members, the society is recognized as a leading authority and information source on cosmetic and
reconstructive plastic surgery. The society represents physicians certified by
The American Board of Plastic Surgery or The Royal College of Physicians
and Surgeons of Canada.
email: jhomewood@auxilium.com
www.auxilium.com
Axogen
Booth: 14
Douglas Silber
Aptis Medical
Booth: 31
Barbra Chesher
13859 Progress Boulevard
Suite 100
Alachua, FL 32615
phone 386-462-6816
fax 386-462-6801
Aptis Medical
3602 Glenview Ave
Phone 502-523-6738
fax 502-425-7422
The ASPN would like to thank AxoGen
for their generous support.
email: dsilber@axogeninc.com
www.axogeninc.com
email: barbaric@aptismeidcal.com
www.aptismedical.com
AxoGen™ Nerve Regeneration provides surgeons with solutions to repair
and regenerate peripheral nerves, bringing relief and restoring function to
patients who suffer peripheral nerve injuries. AxoGen is a leader in the
advancement of peripheral nerve repair – creating a unique combination of
patented technologies and a rich pipeline of new products.
Aptis Medical specializes in taking current concepts once step further. With
the proven success of the Scheker DRUJ prosthesis, Aptis has provided the
only product that replaces the entire DRUJ, prevents subluxation and allows
the bearing of weight. Other new and innovated designs for joint replacement are soon to follow.
Ascension Orthopedics
Booth: 7
Laura Lattimer
8700 Cameron Rd.
Austin, TX 78754
phone 512-836-5001
fax 512-836-5145
The ASPN & ASRM would like
to thank ASSI for their generous support.
BioMet Trauma
Booth: 16
Charlie Eaton
100 Interpace Parkway
Parsippany, NJ 07054
phone 973-299-9300
fax 973-299-0391
The AAHS, ASPN & ASRM would like
to thank Ascension Orthopedics for
their generous support.
email: Charlie.eaton@ebiomed.com
www.bimedtrauma.com
email: llatimer@acensionortho.com
www.ascensionortho.com
Ascension Orthopedics is dedicated to combining advanced materials with
innovative designs, focusing on extremity surgery, and leading the field in surgeon education. Our founders are pioneers in using advanced materials to
combat the debilitating effects of arthritis. Our goal is to provide solutions for
all areas of surgery – reconstruction, trauma and tissue regeneration.
Biomet Trauma develops and markets a full range of internal and external
orthopedic devices used for hand/upper extremity fracture fixation. This
includes Variable Pitch Compression Screws, OptiROM‚ Elbow Fixator, a
Proximal Humeral Plating System, Distal Radius Plating System with
SphereLockTM technology, humeral nails and a variety of distal radius fixators.
14
Cook Medical
Booth: 10
Jennifer Moore
Hologic, Incorporated
Booth: 26
Laura L. DiGangi
Cook Medical
75 Daniels Way, PO Box 489
Bloomington, IN 47402
Phone 812-339-2235
35 Cosby Drive
Bedford, MA 1730
phone 781-999-7667
fax 781-280-0668
email: jennifermoore@cookmedical.com
www.cookmedical.com
email: ldigangi@hologic.com
www.hologic.com
Cook® Medical presents two unique products: The Cook-Swartz implantable
Doppler Blood Flow probe with new DP-M250 Monitor offers the latest technology for continuous confirmation of vascular patency. Surgisis®, a resorbable
porcine small intestinal submucosa biomaterial provides a scaffold for host tissue remodeling, creating natural, cost-effective alternative to surgical repair.
Fluoroscan® mini C-arm X-ray systems from Hologic are designed for orthopedic surgeons performing minimally invasive surgical procedures of the
extremities, as well as for low-dose, in-office imaging.
DePuy Orthopedics, Incorporated
Booth: 2
Lynn Best
Integra
Booth: 25
Jon Trout
700 Orthopaedic Drive
Warsaw, IN 46580
phone 574-371-4979
fax 574-372-7382
311 Enterprise Drive
Plainsboro, NJ 8536
phone 609-275-0500
fax 609-799-3297
email: lbest@dpyw.jnj.com
DePuy Orthopaedics Inc., a Johnson and Johnson Company, is the world’s
oldest and largest orthopaedic company and is a leading designer, manufacturer and distributor of orthopaedic devices and supplies. DePuy products are
used in both surgical and non-surgical therapies to treat patients with musculoskeletal conditions resulting from degenerative diseases, deformities, trauma
and sports related injuries.
The AAHS would like to thank Integra
email: jtrout@integra-ls.com
www.integra-ls.com
Integra develops, manufactures, and markets medical devices for neuro-trauma and neurosurgery, plastic and reconstructive surgery and general surgery. Integra’s peripheral nerve surgery products include NeuraGen™ for
completely severed nerves and NeuraWrap™ for compressed, scarred or
partially injured nerves.
The Guatemala Healing
Hands Foundation
Booth: Specialty Day Only
Mona Lipson
La Federacion De Mano
Booth: 39
Eduard Gonzalez-Hernandez
290 6th Avenue
Brooklyn, NY 11215
phone 718-768-5927
edmexch@hotmail.com
www.demano.org
email: monalipson@hotmail.com
www.guatemalahands.org
“The purposes of La Fed are charitable, educational and scientific.
Specifically, La Fed shall support the highest level of care for patients with
upper extremity disorders through the exchange of ideas and resources, and
increased cooperation and understanding among hand care professionals in
North America, Central America and the Caribbean”
GHHF is a nonprofit organization dedicated to improving the quality and
availability of hand care in Guatemala through education, surgery, and therapy. Specializing in the treatment of congenital and hand injuries, we aim to
reach the Guatemalan population through medical missions led by a volunteer
team of specialized and skilled surgeons, therapists, and dedicated volunteers.
Hand Rehabilitation Foundation
Booth: 34
Leslie Ristine
Leica
Booth: 24
Daria Cardinali
834 Chestnut Street, G114
Philadelphia, PA 19107
phone 215-925-4579
fax 215-925-2386
2345 Waukegan Rd.
Bannockburn, IL 60015
phone 845-702-6727
fax 847-405-2075
email: lristine@handfoundation.org
email: daria.cardinali@leica-microsystems.com
www.surgicalscopes.com
The Hand Rehabilitation Foundation, established in 1975, is a 501(c)3 non
profit corporation formed to promote research and education, and disseminate information to physicians and therapists who work with children and
adults with hand disorders caused by injury, disease or present at birth.
Leica Microsystems will introduce the HM500, the world's only headmounted surgical microscope with variable zoom from 2.0x to 9.0x, Autofocus,
and a working distance of 300mm to 70mm.
15
Marasco & Associates,
Healthcare Architects/Consultants
Booth: 18
John Marasco
Medtronic
Booth: 33
Karen Inman
6743 Southpoint Drive North
Jacksonville, FL 32216
phone: 904-296-9600
toll free: 800-874-5797
fax: 904-281-0966
475 Lincoln Street #150
Denver, CO 80203
Phone 303-832-2887
Fax 3030-861-0760
email: john@marasco-assoicates.com
www.marasco-associations.com
email: karen.inman@medtronic.com
www.medtronic.com
Marasco & Associates is a national architecture and consulting firm, dedicated to providing quality facility design and development assistance for outpatient medical facilities, private physician groups, hospitals and institutional
clients. We are the industry leaders developing 300+ ASC's, 15+ Surgical
Hospitals and over 1,500 healthcare facilities nation wide.
Medtronic ENT is a leading developer, manufacturer and marketer of surgical products for use by ENT specialists. Medtronic ENT markets over 5,000
surgical products worldwide addressing the major ENT subspecialties – Sinus,
Rhinology, Laryngology, Otology, Pediatric ENT. and Image Guided Surgery.
Micrins Surgical
Booth: 1
Bern Teitz
Mast Biosurgery
Booth: 29
Dave Goodman
28438 Ballard Drive
Lake Forest, IL 60048
phone 847-549-1410
fax 847-549-1510
6749 Top Gun Street, Suite 108
San Diego, CA 92121
Phone 858-550-8050
fax 858-550-8060
email: bern@micrins.com
www.micrins.com
email: dgoodman@mastbio.com
www.mastbio.com
MICRINS is featuring some of our most popular instruments and accessories for Hand Surgery, Micro-Reconstructive Surgery and Asesthetic
Surgery. With over 3500 different patterns, we are certain that we will
have just the right instrument that you are looking for. Make a point to
stop by the MICRINS booth to see what's new.
Medartis
Booth: 11
Linda Smith
Microsurgery Instruments Incorporated
Booth: 32
Nancy Kang
127 W. Street Road, Suite 203
Kennett Square, PA 19348
phone 610-961-6101
fax 610-961-6108
7211 Regency Sq. Blvd, #223
Houston, TX 77036
phone 713-664-4707
fax 713-664-8873
The AAHS would like to thank Medartis
MICROSURGERY INSTRUMENTS, INC.
email: microusa@microsurgeryusa.com
email linda.smith@medartis.com
www.medartis.com
Microsurgery Instruments, Inc. is one of the leading suppliers of instruments
and surgical loupes in the United States. We are well known in a large number of surgical fields. Apart from high-quality loupes (from 2.5x to 11x), we
also have super-cut scissors, titanium instruments, vascular clamps, headlights,
sutures, microscopes and other surgical instruments.
Medartis is recognized as an innovator of Polyaxial screw fracture fixation
of the Hand and Radius. Surgeons position the plate where the anatomy dictates and angle each screw for optimal fixation. Since 2001, Medartis continues to develop exceptional implants and elegant instrumentation, finely
crafted in the Swiss tradition of Orthopedics.
®
MMI
Booth: 13
Melissa Rattle
Med Link USA
Booth: 23
Tod Kellen
6000 Poplar Avenue
Memphis, TN 38119
phone 901-685-7557
fax 901-683-7077
PO Box 42483
Des Moines, IA 50323
phone: 800-762-7921
fax: 800-329-5990
email: mrattle@mmi-usa.com
www.mmi-usa.com
MMI is the U.S. Subsidiary of Memometal Technologies. Founded in 1992,
Memometal Technologies is one of the only fully integrated manufacturers of
Nitinol (NiTi) in the world. Memometal produces their Nitinol products from
raw material (melting) to the final sterile implant. In 2002, Memometal
Technologies began a strategic effort to concentrate its core technology and
efforts in the extremity market (hand/wrist/elbow and foot/ankle).
email: tkellen@medlinkusa.com
www.medlinkusa.com
Medlink Manufactures the only microscope designed exclusively for the reconstructive micro-surgeon
16
Novadaq
Booth: 19
Gagan Gill
Schering Corporation
Booth: 6
Linda Sheehan
2585 Skymark Ave, Suite 306
Mississauga, ON Canada L4W4L5
phone 905-629-3822 ext. 216
fax 905-629-0282
2000 Galloping Hill Rd.
Kenilworth, NJ 77033
phone 908-298-4000
email: linda.sheehan@spcorp.com
email: ggill@novadaq.com
www.novadaq.com
Novadaq Technologies develops imaging systems for the operating room.
Novadaq markets the SPY® Intra-operative Fluorescence Imaging System that
enables surgeons performing complex reconstructive micro-surgery to safely and
easily visually locate perforator vessels, assess the quality of blood flow in cojoined vessels and evaluate associated tissue perfusion in the operating room.
Small Bone Innovations, Inc.
Booth: 7
Caralyn Foster
1380 South Pennsylvania Avenue
Morrisville, PA 19067
phone 215-428-1791
fax 215-428-1805
OrthoScan, Inc.
Booth: 9
Tiffany Townsend
email: cfoster@totalsmallbone.com
www.totalsmallbone.com
8212 E. Evans Rd.
Scottsdale, AZ 85260
phone 480-503-8010
fax 480-503-8011
Small Bone Innovations, Inc. (“SBI”) is focused on the needs of the small bone
& joint surgeon resulting in surgeon designed and clinically proven products.
SBI is continually expanding its portfolio to become the worldwide leader in
the design, development, manufacture, and marketing of upper and lower
extremity medical devices.
email: tiffany.townsend@orthoscan.com
www.orthoscan.com
Orthoscan brought “Mini” back to Mini C-Arms, with a light weight, easy to
use, high definition system. We have a larger, more detailed image with
superior automatic dose rate. OrthoScan is 100% dedicated to orthopedic
surgeons and to Mini C-Arms.
Springer
Booth: 40
Anna Unger
OsteoMed
Booth: 4
Tara Gordon
233 Spring Street
New York, NY 10013
phone 212-460-1540
fax 201-272-1898
3885 Arapaho Road
Addison, TX 75001
phone: 972.677.4695
fax: 972.677.4731
email: anna.uger@springer.com
www.springer.com
Springer is part of Springer Science+Business Media, one of the world’s leading suppliers of scientific and specialist literature. Springer publishes over
1,700 journals, more than 5,500 new books a year, and the AAHS’ official
journal, HAND. Stop by the booth to pick up your free sample copy of HAND.
email: tgordon@osteomed.com
www.osteomed.com
OsteoMed Small Bone Orthopedics offers the Hand and Upper Extremity surgeon premium implant products and quality service. The company's success
is driven by its ability to develop and deliver innovative, quality products that
improve patient outcomes and offer technically advanced, simple and cost
effective solutions.
Stryker Trauma & Extremities
Booth: 22
Nahuel L. Quiroga
Saunders, Mosby, Elsevier
Booth: 5
Kelly Dusenberry
325 Corporate Drive
Mahwah, NJ 7430
phone 201-831-6668
fax 201-831-3668
3473 Sitio Borde
Carlsbad, CA 92009
phone 760-944-9906
fax 760-944-9926
The AAHS would like to thank Stryker
email: nahuel.quiroga@stryker.com
www.stryker.com
Stryker Extremities is focused on delivering Trauma products to meet the needs
of surgeons so they can best treat their patients. Stryker’s full line of products
includes plates, nails, external fixation, nerve repair and bone substitutes.
Stryker Extremities is ideal for surgeons that treat fractures from the Hand to
the Proximal Humerus.
email: kdusenberry@elsevier.com
www.elsevier.com
Elsevier-Saunders-Mosby- is the world’s largest medical book publisher. The
latest hand therapy and surgery textbooks will be available for viewing.
17
Synovis Micro Companies Alliance
Booth:15
Lindsay Walls
TriMed, Incorporated
Booth: 12
Tania Klein
439 Industrial Lane
Birmingham, AL 35211
phone 205-941-0111
fax 205-941-1522
25864 Tournament Road
Valencia, CA 91355
phone 508-668-0988
fax 508-668-0212
The ASPN & ASRM would like to thank
Synovis for their generous support.
The AAHS would like to thank TriMed
email: lindsay.walls@synovismicro.com
www.synovis.com
email: Tania@trimedortho.com
www.trimedortho.com
Choice in nerve conduits, S&T® Collagen Matrix – for soft tissue repair, Biover
disposable microvascular clamps, and the Life optics Varioscope® - the
world’s smallest head-mounted operating microscope.
Founded in 1995, TriMed revolutionized the treatment of distal radius fractures. TriMed® is one of the most dynamic companies in the field of
orthopaedics with its Advanced Fixation Technologies™. The company specializes in small fragment and peri-articular fractures fixation and holds
numerous patents on its innovative fracture fixation products.
Synthes
Booth: 3
Rebecca Peck
ViOptix, Incorporated
Booth: 28
Denise Yarmlak
1301 Goshen Parkway
West Chester, PA 19380
phone 610-719-6892
fax 610-719-6533
44061-B Old Warm Springs Boulevard
Fremont, CA 94538
phone 510-226-5806 x 217
fax 510-226-5864
email: puksta.andrea@synthes.com
www.synthes.com
Synthes is a leading global medical device company. We develop, produce
and market instruments, implants and biomaterials for the surgical fixation,
correction and regeneration of the human skeleton and its soft tissues.
email: yarmlakd@vioptix.com
www.vioptix.com
The ViOptix™ Tissue Oximeter provides continuous, non-invasive, direct, realtime measurements of local tissue oxygen saturation. It is used for post-operative monitoring of flaps and digit replants to assess and monitor tissue, thereby improving medical outcomes and decreasing cost. The system consists of
a monitor and sterile single-use optical sensors.
Toby Orthopaedics
Booth: 8
James Janoff
3773 Matheson Avenue
Coconut Grove, FL 33133
phone 305-665-8699
fax 305-768-0269
email: jmj@tobyortho.com
www.tobyortho.com
Toby Orthopaedics is dedicated to success through design innovation that
allows for true advances in orthopaedic surgery. Redefining convention, finding solutions, and broadening the application of our next-generation technology through superior design and craftsmanship. Toby products strive to be
more efficient, saving time and money for surgeons and hospitals alike.
Tornier
Booth: 27
Michael Maunu
11035 Roselle Street
San Diego, CA 92121
phone 858-875-4195
fax 858-866-0328
The ASRM would like to thank ViOptix
The AAHS, ASPN & ASRM would like
to thank Tornier for their generous support.
email: mmaunu@tornier.com
www.tornier-us.com
The TORNIER Company is a global orthopaedic medical device company
specializing in the design, manufacture and marketing of reconstructive joint
devices. Please visit our booth and see our comprehensive portfolio of innovative products for upper extremity applications including the CoverLoc™
Volar Plate.
18
AAHS CONTINUING MEDICAL EDUCATION INFORMATION
AMERICAN ASSOCIATION FOR HAND SURGERY
OBJECTIVES: Following completion of this course, participants should be able to:
1. Present clinical and basic science research on hand and upper extremity problems.
2. Integrate principles of hand therapy with surgical management of hand and upper extremity problems.
3. Review surgical and nonsurgical principles of managing common hand and upper extremity problems.
4. Review the intellectual discourses through an integrated program with the related surgical societies
(AAHS, ASRM and the ASPN) and resolve conflicts were possible.
5. Implement bioskills courses and enhance management of fractures, arthritis and congenital problems.
6. Present clinical and nonclinical hand therapy issues for a variety of hand problems and fractures.
7. Encourage the exchange of knowledge and expertise of the various specialties involved with hand surgery.
METHODS TO ACHIEVE THESE OBJECTIVES WILL BE:
1. Original research will be presented as papers in an open session that will encourage audience participation.
2. Recognized experts will present instructional courses and panels on hand and upper extremity problems.
3. Hand therapy principles will be reviewed on a special focused day and throughout the meeting.
4. A combined meeting with outstanding papers contributed by the AAHS, ASRM and ASPN.
5. Bioskills courses will be presented on operative procedures related to fractures and arthritis using cadaver
dissections, saw bones and lecture materials to illustrate surgical techniques.
After completion of this program, participants will have an enhanced knowledge of the scope and application
of surgical techniques, treatment a management of fractures, arthritis and congenital problems. As well as
methods to avoiding problems with the Distal Radius Fixation and ways to avoid and manage trauma.
ACCREDITATION/CME
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through
the joint sponsorship of the American Society of Plastic Surgeons and American Association for Hand Surgery. The American Society of Plastic Surgeons is accredited by
the ACCME to provide continuing medical education for physicians.
The American Society of Plastic Surgeons designates this educational activity for a maximum of 31.5 AMA PRA Category 1 credits™. Physicians should only claim credit
commensurate with the extent of their participation in the activity.
(Credit hours subject to change):
AAHS Annual Meeting
January 7-10, 2009
8.25 credits
Specialty Day
January 7, 2009
6.5 credits
Trauma Pre-Course
January 7, 2009
4.75 credits
Comprehensive Hand Surgery Review Course
January 9, 2009
5.0 credits
AAHS/ASRM/ASPN Combined Day
January 10, 2009
5.0 credits
Additional CME credits are available for Instructional/Bioskills Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows:
Course #
Instructional Courses 101 – 106
1.0 credit each
1.0 credit each
1.0 credit each
1.0 credit each
Bioskills Courses BC1-BC3
2.0 credits each
AAHS/ASPN/ASRM Combined Day Instructional Courses
1.0 credit each
Credit hours are subject to program changes.
COPYRIGHT
All of the proceedings of the annual meeting, including the presentations of scientific papers, are intended solely for the benefit of the membership of the American
Association for Hand Surgery. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or presentation is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved
to the speaker or to the American Association for Hand Surgery. Any sound reproduction, transcript, or other use of material presented at the meeting without
the permission of the speaker or the American Association for Hand Surgery is prohibited to the full extent of common law copyright in such material.
THE USE OF CAMERAS OR PHOTOGRAPHIC EQUIPMENT IS NOT PERMITTED DURING THE PRESENTATION OF SCIENTIFIC PAPERS.
19
ASPN CONTINUING MEDICAL EDUCATION
1. Describe and discuss the pathophysiology and the management of chronic pain.
2. Analyze and discuss the different options of managing patients with recurrent entrapment neuropathy.
3. Examine the emerging technologies in the management of nerve injuries.
4. Explain and discuss new advances in understanding the concept of pain.
5. Describe and discuss the evolving management of different pain syndromes.
1. Scientific presentations on current and recent advances in defining the concept of pain.
2. Lectures from invited experts on specific topics related to the management of chronic pain syndromes.
3. Panel discussions on new approaches to identifying and managing failed or recurrent entrapment neuropathies.
4. Instructional courses on different topics related to nerve biology, pathophysiology and injury.
After the completion of this program, participants will have an enhanced knowledge of the pathophysiology and
the management of chronic pain including the scope and application of surgical techniques used in treating
different chronic pain syndromes and recurrent entrapment neuropathy.
ACCREDITATION/CME
the joint sponsorship of the American Society of Plastic Surgeons and American Society for Peripheral Nerve. The American Society of Plastic Surgeons is accredited by the
ACCME to provide continuing medical education for physicians.
The American Society of Plastic Surgeons designates this educational activity for a maximum of 15.5 AMA PRA Category 1 credits™. Physicians should only claim credit
commensurate with the extent of their participation in the activity. (Credit hours subject to change)
ASPN Annual Meeting
January 9-11, 2009
10.5 credits
January 10, 2008
3.0 credits
Additional CME hours are available for Instructional Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows:
Course #
Instructional Courses 301-306
1.00 credit each
AAHS/ASPN/ASRM Combined Day
1.0 credit each
COPYRIGHT
All of the proceedings of the annual meeting, including the presentations of scientific papers, are intended solely for the benefit of the membership of the American
Society for Peripheral Nerve. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or presentation is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved
to the speaker or to the American Society for Peripheral Nerve. Any sound reproduction, transcript, or other use of material presented at the meeting without the
permission of the speaker or the American Society for Reconstructive Microsurgery is prohibited to the full extent of common law copyright in such material.
Disclaimer
The views expressed and the subject material presented in the course of any activities sponsored by the American Society for Reconstructive Microsurgery including lectures, seminars, instructional courses, or otherwise, represent the personal views of the individual participants and do not represent the opinion of the
American Society for Peripheral Nerve. The Society assumes no responsibility for such views or materials, or implied, for the content of any Society sponsored
presentations. Further, the Society hereby acknowledges that while its broad purpose is to promote the development and exchange of knowledge pertaining to
the practice of microsurgery; it does so only in the context of a private forum without making any representation to the public whatsoever. Accordingly, the Society
declares that its primary purpose is to benefit only its members, and responsibility of the Society for acts or omissions of Society members dealing with the public is hereby expressly disclaimed.
20
ASRM CONTINUING MEDICAL EDUCATION
1. Produce a symposium whereby members of the American Society for Reconstructive Microsurgery and honored
guests from around the world can meet socially - as well as professionally - in a relaxed and cordial environment.
2. Produce of an atmosphere of learning and scholarly interaction whereby ideas may be exchanged concerning progress
in microsurgical practice, as well as in the basic science underlying it.
3. Encourage and foster interdisciplinary interaction and promote the cross-fertilization of ideas between members of the
American Association for Hand Surgery, the American Society for Peripheral Nerve and the American Society for Reconstructive Microsurgery.
4. Provide an educational grounding in the principles and scope of microsurgery for fellows, residents and junior faculty, while
bringing practicing physicians up to date on recent developments over a wide range of microsurgical practice.
5. Provide certification for CME requirements in the area of patient safety as well as in specialty specific medical education.
1. Informal collegial interaction between members, guests, residents and fellows will occur in the breaks, during ‘free time’ and
in the course of social events at the resort.
2. Combined symposia – between the American Association for Hand Surgery, the American Society for Peripheral Nerve and the American Society for
Reconstructive Microsurgery – will consist of free papers, invited lectures and panels and will deal with areas of common interest to the three organizations.
3. A “Masters’ course,” focusing on complications and operative problems (“Disasters with the Masters”) will systematically cover most of the subspecialties
within reconstructive microsurgery and will be presented by an expert faculty well experienced in avoiding and getting out of trouble.
4. Free paper sessions will provide diverse contributions from many of the centers where microsurgery is practiced. They will cover
the full spectrum of the specialty including basic science, breast, hand, torso, head and neck, and lower limb. These original
presentations will contain the germ of microsurgery’s future. Discussion will be encouraged.
5. A limited number of major panels will cover the broad areas of microsurgical practice and will serve as a general update on the specialty as a whole.
6. A large number of ‘mini-panels’ involving relatively junior faculty combined with seasoned experts will tackle specific areas of interest. It is expected
that each mini-panel will act as a focus group for individuals who share common problems and who have similar clinical and scientific pursuits.
7. Patient Safety CME certification will be available by meeting participation and specialized computer modules available throughout the program.
After the completion of this program, participants will have an enhanced knowledge of the scope, practice, and application of
microsurgical techniques in breast, upper/lower extremity and head and neck reconstruction. Including the specifics of patient
and flap selection, inset techniques, and avoidance and management of complications.
ACCREDITATION/CME
the joint sponsorship of the American Society of Plastic Surgeons and American Society for Reconstructive Microsurgery. The American Society of Plastic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
The American Society of Plastic Surgeons designates this educational activity for a maximum of 23.75 AMA PRA Category 1 credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity. (Credit hours subject to change):
January 10, 2009
3.0 credits
ASRM Master Series in Microsurgery
January 10, 2009
4.0 credits
ASRM Annual Meeting
January 10-13, 2009
15.0 credits
ASRM/ASRT
January 13, 2009
3.0 credits
ProgrammingAdditional CME hours are available for Instructional Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows:
Course #
Mini-Panels 1S-6S
Mini-Panels 1M-4M
Mini-Panels 1T-6T
CME
1.25 credit each
1.25 credit each
1.25 credit each
AAHS/ASPN/ASRM Combined Day
1.0 credit each
COPYRIGHT
All of the proceedings of the annual meeting, including the presentations of scientific papers, are intended solely for the benefit of the membership of the American Society
for Reconstructive Microsurgery. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or presentation
is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker or
to the American Society for Reconstructive Microsurgery. Any sound reproduction, transcript, or other use of material presented at the meeting without the permission of
the speaker or the American Society for Reconstructive Microsurgery is prohibited to the full extent of common law copyright in such material.
Disclaimer
The views expressed and the subject material presented in the course of any activities sponsored by the American Society for Reconstructive Microsurgery including lectures,
seminars, instructional courses, or otherwise, represent the personal views of the individual participants and do not represent the opinion of the American Society for
Reconstructive Microsurgery. The Society assumes no responsibility for such views or materials, or implied, for the content of any Society sponsored presentations. Further,
the Society hereby acknowledges that while its broad purpose is to promote the development and exchange of knowledge pertaining to the practice of microsurgery; it does
so only in the context of a private forum without making any representation to the public whatsoever. Accordingly, the Society declares that its primary purpose is to benefit
only its members, and responsibility of the Society for acts or omissions of Society members dealing with the public is hereby expressly disclaimed.
21
American Association for Hand Surgery
American Society for Peripheral Nerve
American Society for Reconstructive Microsurgery
2009 Annual Meeting
PARTICIPANTS’ DISCLOSURES
THE FOLLOWING ANNUAL MEETING PARTICIPANTS HAVE INDICATED THE FOLLOWING DISCLOSURES:
Brian Adams, MD, serves as a consultant to Ascension Orthopedics.
Alejandro Badia, MD, discloses that he is a Consultant with Mast Biosurgery and references
the Orthowrap material used to wrap nerves after either neruolysis of nerve repair.
Robert Beckenbaugh, MD, receives royalties and travel assistance for laboratory from
Ascension Orthopedics.
Allan J. Belzberg, MD, receives grant support from DOD.
Charles Butler, MD, speaks for and receives clinical & research grant support from Life Cell Inc.
Donald Lalonde, discloses that he is a Consultant for ASSI Instruments.
Wyndell Merritt, MD, serves as a consultant to Micro Aire, and receives royalties for their Epicut Knife.
Michael Samnson, MD, has received consultant honoraria from Closure Medical, Novadaq, and Ethicon. Dr.
Samson has no personal financial interests, stocks, or ownership of the aforementioned companies.
Luis Schecker, discloses that he is a part owner of Aptis Medical LLC
receive royalties for work licensed through Mayo Clinic to a privately held company for
contributions related to the use of nerve signal modulation to treat central, autonomic, and peripheral nervous
system disorders, including pain. Mayo Clinic receives royalties and owns equity in this company. The company does not currently license or manufacture any drug or device in the medical field.
Robert Spinner, MD,
22
2009 Annual Meeting
DISCLOSURES Continued
The following participants have disclosed no conflict of interest.
Alejandro Badia, MD
Mark Baratz, MD
Antonia Barmpitsioti ,MD
Yoav Barnea ,MD
Lynn Bassini, MA, OTR, CHT
Taizoon Baxamusa ,MD
Stephen Bayles ,MD
Richard C. Baynosa ,MD
Elisabeth K. Beahm, MD
Michael S. Bednar ,MD
Aaron J. Berger ,MD
Steven Bernard ,MD
Nada Berry ,MD
Michael Bezuhly ,MD
Kyle Bickel, MD
Sean Bidic ,MD
Paul Binhammer ,MD
Allen T. Bishop, MD
J. Brian Boyd, MD
Warren Breidenbach, MD
Darrell Brooks ,MD
David L. Brown ,MD
Justin M. Brown ,MD
Edward Buchel, MD
Jf Buell ,MD
Fabio Busnardo ,MD
Brian T. Carlsen ,MD
Louis A. Carter, MD
Matthew J. Carty ,MD
Daniel J. Ceradini ,MD
James A. Chambers ,MD
Chang-Cheng Chang ,MD
David Chang, MD
Edward I. Chang ,MD
James Chang, MD
Nai-Jen Chang ,MD
Shi-Min Chang ,MD
James Chang, MD
Benjamin Chang, MD
Chien-Chung Chen ,MD
Hung-Chi Chen ,MD
Ying-an Chen ,MD
Jonathan Cheng ,MD
Ming-Hei Cheng, MD
Hui Ling Chia ,MD
Yuan-Cheng Chiang ,MD
Alvaro B. Cho ,MD
Michael W. Chu ,MD
Kevin Chung, MD
Howard Clarke, MD, PhD
Tyson Cobb ,MD
Peter Cordiero, MD
Brendan J. Collins ,MD
Damon Cooney ,MD
Sheila M. Crean ,MD
Joanna Cwykiel ,MD
T.K.S. Cypel ,MD
Neil D. Dalal ,MD
Tim H.C. Damen ,MD
Joseph H. Dayan ,MD
Ralph De Boer ,MD
A. Lee Dellon, MD
Yavuz Demir ,MD
Brian P. Dickinson ,MD
Kazteru Doi, MD
Michael J. Dorsi ,MD
Ivica Ducic ,MD
Frederick J. Duffy ,MD
William Duggan ,MD
Ahmet Duymaz ,MD
Brent M. Egeland ,MD
Liron Eldor ,MD
Kevin El-Hayek ,MD
Holger Engel ,MD
Jin Sup Eom ,MD
Heather Erhard ,MD
Gregory Evans, MD, PhD
Lars H. Evers ,MD
Margaret Fahnestock ,MD
Jonathan Ferrari ,MD
Neil Fine, MD
Brian Fitzgerald, MD
Michael Fitzmaurice ,MD
R. Jobe Fix, MD
Johnny Franco ,MD
Michael Fritz ,MD
Minako Fukuzawa ,MD
Emre Gazyakan ,MD
Dawn J. Geisler-Wang ,MD
William Geissler, MD
Alexandru Georgescu ,MD
Gunter Germann, MD
Stefano Geuna ,MD
Jennifer Lindsay Giuffre ,MD
Riccardo E. Giunta ,MD
Andreas Gohritz ,MD
Robert Joseph Goitz ,MD
Tessa Gordon ,MD
Daniel Gottlieb, MD
Lawrence Gottlieb, MD
Eyal Gur, MD
Geoffrey Gurtner, MD
Jeffrey Gusenoff ,MD
Ron Gutmark ,MD
Nicholas Haddock ,MD
Tessa A. Hadlock ,MD
Moustapha Hamdi, MD
Nathan Hammel ,MD
Matthew M. Hanasono ,MD
Takaaki Hasuo ,MD
Ryo Hattori ,MD
Francis Patrick Henry ,MD
Kathleen Herbig ,MD
James Higgins, MD
Stephen Higuera ,MD
Hirotsune Hirahara ,MD
Yuichi Hirase ,MD
Mikael Hivelin ,MD
Stefan OP Hofer, MD
Eric P. Hofmeister, MD
Scott T. Hollenbeck ,MD
Joon Pio Hong ,MD
Karen M. Horton ,MD
David A. Houlden ,MD
Chung-chen Hsu ,MD
Jung-Ju Huang ,MD
Bradley A. Hubbard ,MD
Helen Hui-Chou ,MD
Hiroyasu Ikegami ,MD
Ryosuke Ikeguchi ,MD
Asif M. Ilyas ,MD
Jonathan Isaacs ,MD
Selçuk Isik ,MD
Avinash Islur ,MD
Marcos Jaeger ,MD
Shareef Jandali ,MD
Masia Jaume, MD
Craig Johnson, MD
Seth Jones ,MD
Neil F. Jones, MD
Jesse Jupiter ,MD
Gretchen Kaiser Bodell, OTD, OTR/L, MBA, CHT
Ryosuke Kakinoki ,MD
Suhail Kanchwala ,MD
F. Thomas D. Kaplan ,MD
Furkan Erol Karabekmez ,MD
Rahul Kasukurthi ,MD
Adam J. Kaye ,MD
Alex Keller ,MD
Stephen W.P. Kemp ,MD
Mahlon Alder Kerr-Valentic ,MD
Elizabeth M. Kim ,MD
Sendia Kim ,MD
Aleksandra Klimczak ,MD
Jason H. Ko ,MD
L. Andrew Koman, MD
Isao Koshima ,MD
Aaron M. Kosins ,MD
Scott H. Kozin, MD
Leo T. Kroonen ,MD
Tateki Kubo ,MD
Yur-Ren Kuo ,MD
Gi-Doo Kwon ,MD
Adil Ladak ,MD
Laurent A. Lantieri ,MD
Mikko Larsen ,MD
Catherine Lecours ,MD
Steven Leibovic, MD
Mary Lester ,MD
Chih-Hung Lin ,MD
Ching-Chun Lin, MD
Ines C. Lin, MD
Jenny C. Lin, MD
Samuel Lin ,MD
Joan Lipa, MD
Robert Lohman ,MD
Photis Loizides ,MD
Otway Louie ,MD
Ting-Chen Lu ,MD
John Lubhan, MD
Barbara S. Lutz ,MD
Ian F. Lytle ,MD
Susan Mackinnon, MD
Jeffrey V. Macnhio ,MD
Christina M. Magill ,MD
Eric Makhni ,MD
Erik Marques ,MD
David W. Mathes ,MD
Evan Matros ,MD
Steven J. McCabe ,MD
Kenneth R. Means ,MD
Emmanuel G. Melissinos ,MD
Wisam Menesi ,MD
Deana Mercer ,MD
Antonio Merolli ,MD
Ali N. Mesbahi ,MD
Sue Michlovitz, PT, PhD
Makoto Mihara ,MD
Ather Mirza ,MD
Suhail Mithani ,MD
Jose J. Monsivais ,MD
Amy M. Moore ,MD
Thomas J. Moore ,MD
Steven L. Moran ,MD
Mauricio A. Moreno ,MD
Carol Morris, MD
Wayne Morrison, MD
M. Amir Mrad ,MD
Tsuyoshi Murase ,MD
Marc A.M. Mureau ,MD
Robert X. Murphy Jr ,MD
Peter M. Murray, MD
Daniel Nagle, MD
Toshiyasu Nakamura ,MD
Nash Naam, MD
Arthur J. Nam, MD
Sanjay Naran,MD
Mitsunaga Narushima ,MD
Serdar Nasir ,MD
Ross Nathan, MD
David Nelson, MD
Peter C. Neligan, MD
Michael Neumeister, MD
Phuong D. Nguyen ,MD
Milomir Ninkovic, MD
Christine B. Novak ,MD
Eleni Ntouvali ,MD
Yukihiko Obara ,MD
Millicent Odunze ,MD
Jorge Orbay, MD
A. Lee Osterman ,MD
Serdar Ozturk ,MD
Tuna Ozyurekoglu ,MD
Nitin A. Pagedar ,MD
Bradley Palmer ,MD
Jeffery Palmer
Andre Panossian ,MD
Pranay M. Parikh ,MD
Pranay M. Parikh ,MD
Brian M. Parrett ,MD
Michael Pelzer ,MD
Barbara Persons ,MD
Miguel Pirela-Cruz ,MD
Kevin Plancher, MD
Willem Pondaag ,MD
Julian Pribaz, MD
Andrea Pusic, MD
Ariel N. Rad ,MD
Christine Radtke ,MD
Antonio Rampazzo ,MD
Kv Ravindra ,MD
Wilson Z. Ray ,MD
Kevin Renfree, MD
John Thomas Riehl ,MD
Brian Rinker ,MD
Celoa Sue Robinsom ,MD
23
Eduardo Rodriguez, MD
Rachel S. Rohde ,MD
Lawrence Rossi, MD
Gedge D. Rosson ,MD
David E. Ruchelsman ,MD
Laura Rummler ,MD
John Russell ,MD
Robert Russell ,MD
Salim C. Saba ,MD
Sepideh Saber ,MD
Justin M. Sacks ,MD
Michel Saint-Cyr ,MD
Harilaos T. Sakellarides ,MD
Christopher J. Salgado ,MD
Douglas Sammer, MD
Michael Samson, MD
Sven N. Sandeen ,MD
James R. Sanger ,MD
Kumiko Sata ,MD
Toshihiko Satake ,MD
Rebecca J. Saunders ,MD
Thomas Schoeller ,MD
Stefan Schneeberger, MD
Samuel Schroerlucke ,MD
Jeffrey R. Scott ,MD
Iris A. Seitz ,MD
Jesse Creed Selber ,MD
Joseph Serletti, MD
Joy V. Sharma ,MD
Randy Sherman, MD
Minoru Shibata, MD
Alexander Y. Shin ,MD
Jayan Man Shrestha ,MD
Krzysztof Siemionow ,MD
Maria Sieminow, MD
Roman Skoracki, MD
Mia E. Skourtis ,MD
Joseph Slade, MD
Robert R. Slater ,MD
Anthony Smith, MD
Erhan Sonmez ,MD
Dean Sotereanos, MD
Jason A. Spector ,MD
Aldona Spiegel, MD
Marcus Spies ,MD
Robert J. Spinner ,MD
Milan Stevanovic, MD
Hugo St-Hilaire ,MD
Scott Keith Sullivan ,MD
Naoya Takada ,MD
Susumu Tamai, MD
Yueh-Bih Tang Chen ,MD
Martijn R. Tannemaat ,MD
John S. Taras ,MD
Shian Chao Tay ,MD
Shian Chao Tay ,MD
Jesse A. Taylor ,MD
Keri S. Taylor ,MD
Oren Tepper ,MD
Julia Terzis, MD
Hema Thakar ,MD
Achilles Thoma, MD
Michael Thompson, MD
Hirokazu Tochigi ,MD
Matthias Traub ,MD
Steven Trigg, MD
Matthew J. Trovato ,MD
Thomas E. Trumble ,MD
Chung-Kan Tsao ,MD
Stefania Tuinder ,MD
Thomas Tung, MD
Melanie G. Urbanchek ,MD
Allen Van Beek, MD
Nicholas Vedder, MD
Esther Vögelin ,MD
J. Trad Wadsworth, MD
Sarah K. Walsh ,MD
Robert Walton, MD
Huan Wang ,MD
Theresa Y. Wang ,MD
Kirk J. Wangensteen ,MD
Renata V. Weber ,MD
David H. Wei ,MD
Fu Chan Wei, MD
Elizabeth L. Whitlock ,MD
Aviva Wolf, OTR/L, CHT
Alex K. Wong ,MD
Chin-Ho Wong ,MD
Corrine Wong ,MD
Sarah Hew-Ming Wong ,MD
Vanessa Hew-Ling Wong ,MD
Chih-Wei Wu ,MD
Wen-Dong Xu ,MD
Eiko Yamabe ,MD
Jonathan Christian Yang ,MD
Jeff Yao, MD
Peirong Yu ,MD
Abigail Zamora ,MD
Arik Zaretski ,MD
Andrew Y. Zhang ,MD
Yi Xin Zhang ,MD
Fatih Zor ,MD
H. Mischa Zuijdendorp ,MD
Ronald Zuker, MD
Future Annual
Meeting Locations
AAHS
2010 Annual Meeting
January 6 – 9, 2010
Boca Raton Resort and Club
Boca Raton, Florida
ASPN
2010 Annual Meeting
January 8 – 10, 2010
Boca Raton Resort and Spa
Boca Raton, Florida
ASRM
2010 Annual Meeting
January 9 – 12, 2010
Boca Raton Resort and Club
Boca Raton, Florida
2011 Annual Meeting
January 12 – 15, 2011
Ritz Carlton Cancun
Cancun, Mexico
2011 Annual Meeting
January 14 – 16, 2011
Ritz Carlton Cancun
Cancun, Mexico
2011 Annual Meeting
January 15 – 18, 2011
Ritz Carlton Cancun
Cancun, Mexico
2012 Annual Meeting
January 11 – 14, 2012
Red Rock Casino Resort & Spa
Las Vegas, Nevada
2012 Annual Meeting
January 13 – 15, 2012
Las Vegas, Nevada
2012 Annual Meeting
January 14 – 17, 2012
Las Vegas, Nevada
24
DAY-AT-A-GLANCE
Wednesday, January 7, 2009
6:30am – 5:00pm
Speaker Ready Room
Silversword
6:30am – 5:00pm
Meeting Services
Convention Registration Desk
6:00am – 7:00am
Continental Breakfast
Haleakala 2 and 3
7:00am – 3:00pm
Specialty Day Program: Complex Trauma:
Management and Rehabilitation.
Haleakala 2 and 3
9:35am – 9:55am
Coffee Break
Haleakala Ballroom Foyer
11:30am – 1:00pm
AAHS Past President’s Luncheon
Molokini Bistro
12:00pm – 1:00pm
Specialty Day Lunch
Haleakala 2 and 3
1:00pm – 6:00pm
Trauma Pre-Course: Standard of Care or
Stretching the Indications
Haleakala 5
5:00pm – 6:00pm
Hand Therapists’ Reception
Grand Dining Room
6:00pm – 8:00pm
AAHS Welcome Reception
Grand Dining Room
25
AAHS: Wednesday,
January 7, 2009
9:55am – 11:00am
6:00am – 7:00am
Continental Breakfast
7:00am – 3:00pm
Specialty Day Program: Complex Trauma:
Management and Rehabilitation
7:00am – 7:15am
Lynn Bassini, MA, OTR, CHT
11:00am – 12:00pm
Welcome
11:30pm – 1:00pm
AAHS Past President’s Luncheon
12:00pm – 1:00pm
Specialty Day Lunch
1:00pm – 2:00pm
Case Studies: What I Learn When Things Go
Awry: Modified Methods for Maximal Outcomes
Traumatic cases often lend challenge to clinical decision making and lead to less than optimal outcomes. This panel will
review such cases and determine alternatives for clinical reasoning and intervention to facilitate maximal function.
Miguel Pirela-Cruz, MD, Program Chair
Aviva Wolff, OTR/L, CHT, Moderator
Mary Nordlie, MS, OTR/L. CHT
Ann Lund, OTR/L, CHT
Cia Passig, OTR/L, CHT
Rebecca Von Der Heyde, MS, OTR/L, CHT, Specialty Day Chair
2:00pm – 3:00pm
7:15am – 8:15am
Traumatic Amputations
7:15am – 7:35am
Putting It Back Together Again: Surgical
Replantation
Techniques for surgical replantation following traumatic
amputation will be discussed, including indications, complications, and post-operative management.
1:00pm – 6:00pm
Finding the Happy Medium: Splinting and
Motion Following Replantation
Randy Bindra, MD, Moderator
$100 Additional Registration Required.
1:00pm – 1:20pm
Plating is the Optimal Treatment for
Displaced Clavicle Fractures
Gretchen Kaiser Bodell, OTD, OTR/L, MBA, CHT
1:20pm – 1:40pm
Nerve Transfers Provide a More Predictable
Outcome Than Proximal Nerve Repairs
Thomas Tung, MD
To Salvage or Not to Salvage? Case
Presentations
1:40pm – 2:00pm
Should We Always Reconstruct the Ulnar Artery
in Hypothenar Hammer Syndrome?
Craig Johnson, MD
2:00pm – 2:20pm
Is Replantation of Single Finger Distal to the
FDS Insertion Still a Valid Indication?
Minoru Shibata, MD
2:20pm – 2:40pm
2:40pm – 3:10pm
Q&A
Susan Mackinnon, MD
3:10pm – 3:30pm
3:30pm – 3:50pm
Break
Power Surge: Rehabilitation Following Nerve
Grafting and Transfers
3:50pm – 4:10pm
The Role of Bone-Ligament-Bone Repair for
Acute Scapholunate Dissociations
Richard Berger, MD
4:10pm – 4:30pm
The Hamatometacarpal Joint: Is It Just
for Spare Parts for the PIP?
Greg Sommerkamp, MD
4:30pm – 4:50pm
Usefulness of 2-Stage Reconstruction in
Neglected Profundus Tendon Ruptures
John Taras, MD
4:50pm – 5:10pm
The Role of Ulnar Head Replacement in
Distal Ulna Fracture Reconstruction
Brian Adams, MD
5:10pm – 5:30pm
5:30pm – 6:00pm
Q&A
5:00pm – 6:00pm
6:00pm – 8:00pm
Hand Therapist Reception
Nicholas Vedder, MD
Restoration of Power: Nerve Grafting
and Transfers
The latest advances in peripheral nerve reconstruction will be
presented as surgical options following traumatic injuries.
8:35am – 8:55am
Intervention strategies and expectations for functional return will
be discussed for the post-operative management of nerve grafts.
Christine Novak, MS, PT
8:55am – 9:15am
Role Reversal: Nuts and Bolts of Tendon Transfers
Indications and techniques for post-traumatic tendon transfers
will be offered with attention to donor options and functional
expectations.
Scott Kozin, MD
9:15am – 9:35am
Trauma Pre-Course: Standard of Care or Stretching
the Indications - Additional CME 4.75 Credits
The return to function following replantation requires a careful
balance between motion and protection. The challenges of
post-operative rehabilitation will be analyzed as they relate to
successful outcomes.
Complex trauma cases will be presented with a focus on surgical decision making prior to replantation and salvage procedures.
8:15am – 8:35am
Your Statistician’s Diagnosis: How to Tell
When You Need a Second Opinion on Your
Research Project
You're planning a clinical study and (of course) will consult a
statistician as you design the study. Your statistician should ask
you certain questions about your study. This course will help
you decide whether your statistician understands your study or
whether it is time to get a second opinion.
Paul Velleman, PhD
7:55am – 8:15am
Panel: Multi-Trauma Case Presentations
Trauma cases with extensive involvement of bone, nerve,
muscle, and soft tissue require advanced decision making for
both surgeon and therapist. Case presentations will be analyzed by multiple panel members, including suggestions for
surgical and rehabilitative decision making.
Miguel Pirela-Cruz, MD, Moderator
Paul Brach, PT, CHT
James Chang, MD
Scott Kozin, MD, President
7:35am – 7:55am
Panel: Hands Around the World:
Complex Cases from Medical Missions
Traumatic cases, while challenging to manage at home, often
require multiple levels of collaboration when encountered during a medical mission. This panel will present case studies that
exemplify the challenges and successes associated with
mission work.
Finding a New Path: Neuromuscular Re-Education
Practical methods of neuromuscular re-education will be delineated for the post-operative rehabilitation of tendon transfers.
Debate: All Stable Distal Radius Fractures should
be Offered Surgery
Thomas Hunt, MD
David Nelson, MD
Should All Scaphoid Nonunions Have a
Vascularized Bone Graft?
Alexander Shin, MD
Debate: All Non-Displaced Scaphoid Fractures
Should Be Fixed With a Screw
Peter Amadio, MD
Joseph Slade, MD
Aviva Wolff, OTR/L, CHT
9:35am – 9:55am
Coffee
Supported by:
26
AAHS Welcome Reception
DAY-AT-A-GLANCE
Thursday, January 8, 2009
6:00am – 3:30pm
Speaker Ready Room
Silversword
6:00am – 4:30pm
Meeting Services
6:00am – 7:30am
Coffee
6:00am – 5:00pm
AAHS Poster Viewing
6:30am – 7:30am
Instructional Courses
101 CMC Arthritis: Arthroscopy, Anchovy, Implants
102 Flexor Tendon Repair- Are We Any Better?
103 Scapholunate Ligament: An Update on Repair
104 Success in Private Practice: Surgical Centers,
Therapy, Passive Income, Reimbursement
105 Total Wrist Arthroplasty
106 Treatment of Complications after Wrist Fracture
Pikake
Ilima 2 & 3
Maile 2 & 3
Plumeria 2 & 3
Hibiscus 3
Hibiscus 1 & 2
7:45am – 8:45am
President/Program Chair Welcome
AAHS Presidential Welcome
Program Chair Welcome
ASSH Presidential Welcome
Vargas Recipient Welcome
Haleakala 1
8:45am – 10:15am
PANEL: Minimally Invasive Fracture Fixation
Haleakala 1
9:00am – 9:30am
Breakfast
Haleakala Gardens
9:30am – 10:30am
Hand Editorial Board Meeting
Maile 1
9:30am – 11:00pm
Concurrent Scientific Paper Session A-1
Haleakala 1
9:30am – 11:00am
Concurrent Scientific Paper Session A-2
Haleakala 2 & 3
11:15am – 12:00pm
Presidential Address: Scott H. Kozin, MD
12:00pm – 1:15pm
Keynote Speaker: Daniel Gottlieb, PhD (spouses welcome)
Haleakala 1
1:15pm – 1:30pm
Vice Speaker AMA House of Delegates:
Andrew W. Gurman, MD
Haleakala 1
1:30pm – 2:30pm
AAHS Instructional Courses
107 Elbow Trauma and Coverage
108 Intercarpal Fusions
109 Nerve Compression and Repair
110 Pediatric Brachial Plexus Injury
111 Scaphoid Fractures & Nonunions
112 Tendonitis, Tendonpathy, Tendon Rupture About the Elbow
Pikake 2 & 3
Ilima 2 & 3
Maile 2 & 3
Plumeri 2 & 3
Hibiscus 3
Hibiscus 1 & 2
Bioskills Courses
BC-1 Endoscopic Cubital Tunnel Release
BC-2 Avoiding Problems with Distal Radius Fixation
BC-3 Surgical Tips in Treating Distal Radius Fractures
Haleakala 4
Haleakala 5
Haleakala 2
113 Nerve Transfers for the Upper Extremity- What Works
114 Burn Management
115 Financial Course- Life Financial Goals for Physicians
Maile 2 & 3
Pikake 2 & 3
Plumeria 2 & 3
3:00pm – 5:00pm
3:30pm – 4:30pm
27
AAHS: Thursday, January 8, 2009
6:00am – 7:30am
Coffee
6:00am – 5:00pm
AAHS Poster Viewing
6:30am – 7:30am
Instructional Courses - Additional
CME 1 credit each
9:30am - 11:00am
CONCURRENT SCIENTIFIC PAPER SESSION A-1
Moderators: John Lubahn, MD and Sue Michlovitz, PT, PhD, CHT
*Designates resident/fellow paper presentations
Supported by:
9:30am – 9:35am
The Use of Pyrolytic Carbon for the Treatment of Complex Post Traumatic
Arthritis and Acute Joint Loss in the MCP and CMC Joint
Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA
Furkan Erol Karabekmez, MD; Ahmet Duymaz, MD; Steven L. Moran
101 CMC Arthritis: Arthroscopy, Anchovy, & Implants
Update regarding advances in the treatment of CMC arthritis.
The current use of arthroscopy in the treatment paradigm and the
role of implants will be highlighted. These newer treatment
modalities will be compared to the gold standard “anchovy”
surgeries.
9:35am – 9:40am
Biomechanical Comparison of Three Fixation Techniques of Four Corner
Arthrodesis: K wires vs Circular plate (Spider Plate) vs Locked Circular plate
(Xpode Plate)
Alexander Y. Shin, MD; Jirachart Kraisarin, MD; Lawrence J. Berglund, BS; David G. Dennison;
Kai-Nan An, PhD
Alejandro Badia, MD, Moderator
John Lubhan, MD
102 Flexor Tendon Repair - Are We Any Better?
This course will lecture on acute repair of the flexor tendons,
review of anatomy, and physiology of healing.
9:40am – 9:45am
Outcome Assesment of Arthroscopic Interpositional Arthroplasty of the
Trapeziometacarpal Joint
Institution where the work was prepared: Brown Hand Center, Phoenix, AZ, USA
Michael Fitzmaurice, MD; P. Stephen Mahoney, MD; Michael Brown, MD
Eduardo Gonzalez-Hernandez, MD, Moderator
Donald Lalonde, MD
Amanda Higgins, OT
103 Scapholunate Ligament: An Update on Repair
9:45am – 9:50am
Short-Term Outcomes of Trapeziometacarpal Artelon Implant Compared with
Abductor Pollicis Longus Tendon Interposition Arthroplasty - A Case-Control
Study
Institution where the work was prepared: Department of Orthopedics, Hässleholm Hospital,
Hässleholm, Sweden
Isam Atroshi, MD, PhD; Ingrid Isaxon, PT; Magnus Flondell, MD; Maria Jörheim, MD; Peter
Kalén, MD, PhD
Update on scapholunate anatomy with reference to repair techniques. Will include a discussion of arthroscopic and open techniques to restore scapholunate stability. Highlight the role of capsulodesis in the treatment regimen.
Richard Berger, MD, Moderator
104 Success In Private Practice (Surgical centers,
Therapy, Passive Income, Reimbursement)
The course will present strategies for maximizing efficiency
and reimbursement in private hand surgery practices. The
presenters will discuss their experiences and the current state
of opportunities and regulations regarding non-clinical sources
or revenue, as well as maximizing reimbursement for clinical
practice activities in today’s challenging practice environment.
9:50am – 9:55am
The Effect on Wrist Flexion Strength of Thumb Carmpometacarpal Joint
Arthroplasty Using the Entire Flexor Carpi Radialis Tendon
Institution where the work was prepared: Curtis National Hand Center, Baltimore, MD, USA
Rebecca J. Saunders, PT/CHT; Michael S. Murphy, MD
Kyle Bickel, MD, Moderator
Allen Berkowitz, MD
Ross Nathan, MD
9:55am – 10:00am
Discussion
105 Total Wrist Arthroplasty: Indications, Surgery
and Rehabilitation
Moderators: Alejandro Badia, MD and Mark Baratz, MD
Total wrist arthroplasty has evolved over the past decade with
changes in technique and implant design. These advances have
expanded the indications for wrist arthroscopy. This course will
discuss the indications, contraindications, technique, rehabilitation, and outcome following total wrist arthroplasty.
10:00am – 10:05am
Long-term Follow-up of Surface Replacement Arthroplasty of the PIP Joint
Peter M. Murray, MD; William P Cooney; Ronald L Linscheid
Brian Adams, MD
106 Treatment of Complications after Wrist
Fracture - Malunion, Nonunion, Infection
*10:10am – 10:15am
Flexor Tendon Tissue Engineering: Bioreactor Cyclic Strain Increases Construct
Strength
Institution where the work was prepared: Stanford University and Palo Alto VA, Palo Alto, CA, USA
Sepideh Saber, BS; Andrew Y. Zhang, MD; Sae H. Ki, MD; Derek Lindsey, MS; Hung M. Pham,
BS; James Chang, MD/FACS
Common complications following wrist fractures include malunion and stiffness. Uncommon complications are infection and
nonunion. This course will discuss ways to minimize problems
during the initial fracture management and methods to handle
specific complications after wrist fracture.
Tom Wright, MD, Moderator
Phil Heyman, MD
Rob Medoff, MD
Jorge Orbay, MD
7:45am – 8:00am
*10:15am – 10:20am
Barbed Suture Tenorrhaphy - An Ex-Vivo Biomechanical Analysis
Institution where the work was prepared: Curtis National Hand Center, Union Memorial Hospital,
Baltimore, MD, USA
Pranay M. Parikh, MD; James Patrick Higgins, MD; Steven Paul Davison, MD, DDS
Welcome
Presidential Welcome Program Chair Welcome
Vargas Award Recipient
ASSH President: L. Andrew Koman, MD
8:00am – 9:00am
10:20am – 10:25am
Brunelli Pull-OutTechnique in Flexor Tendons Repair in Zones II and III: A
Study on 65 Cases
Institution where the work was prepared: University of Medicine Cluj, Spitalul Clinic de
Recuperare, Cluj-Napoca, Romania
Alexandru Georgescu, Prof, MD, PhD; Irina Capota, MD; Filip Ardelean, MD; Ileana Matei, MD
Panel: Minimally Invasive Fracture
Fixation - How I Do It!
The advent of minimally invasive methods to achieve fracture
fixation lessen the soft tissue disruption and theoretically maximizes patient outcome. Percutaneous, arthroscopic, and limited open techniques have been described for a variety of hand
and wrist fractures. This panel will demonstrate various minimally invasive fracture techniques by a penal of experts with
the goal of achieving fracture stability with limited soft tissue
infringement.
10:25am – 10:30am
Discussion
Moderators: John Taras, MD and E. Gene Deune, MD
*10:30am – 10:35am
Flexor Tendon Tissue Engineering: the Biomechanical Analysis of Explanted
Acellularized Tendon Constructs
Institution where the work was prepared: Stanford Hospital and Clinics and the VA Palo Alto
Healthy Care , Palo Alto, CA, USA
Andrew Y. Zhang, MD; Sae H. Ki, MD; Sepideh Saber, BS; Derek Lindsey; Hung M. Pham, BS;
James Chang, MD
Jesse Jupiter, MD, Moderator
Alexander Shin, MD
9:00am – 9:30am
Breakfast
9:30am – 10:30am
Hand Editorial Board Meeting
Supported by:
28
*10:35am – 10:40am
Biomechanical Comparison of Lasso Tendon Repair to Pulvertaft Weave and
Side-to-Side Repairs
Institution where the work was prepared: University of Texas Southwestern Medical Center,
Dallas, TX, USA
Sean Bidic; Anubodh Varshney, BS; Harry Orenstein
10:10am – 10:15am
Corrective osteotomy for intra-articular malunion of the distal
part of the radius
Institution where the work was prepared: Ootawara Red Cross Hospital, 2-7-3 Sumiyoshi-cho
Ootawara-city Tochigi pref, Japan
Hirokazu Tochigi, MD; Kazuki Satou, MD, PhD; Hirofumi Yoshida, MD; Toshiyasu Nakamura,
MD, PhD; Hiroyasu Ikegami, MD, PhD; Yoshiaki Toyama, MD, PhD
*10:40am – 10:45am
Flexor Tendon Repair using Modified Lim and Tsai Six Strand Suture Technique
Institution where the work was prepared: Department Of Surgery, Singapore General Hospital,
Singapore, Singapore
Jayan Man Shrestha, MS, (General, Su; Shian Chao Tay, MD, MS
10:15am – 10:20am
Three-dimensional Corrective Osteotomy of Malunited Fractures of the
Upper Extremity Using a Novel Computer Simulation System and a
Custom-designed Surgical Device
Institution where the work was prepared: Osaka University, Suita, Japan
Tsuyoshi Murase, MD; Kunihiro Oka, MD; Hisao Moritomo; Akira Goto, MD; Sayuri Arimitsu;
Yukari Takeyasu; Junichi Miyake; Kazuomi Sugamoto, MD; Hideki Yoshikawa, MD; Kozo
Shimada, MD
*10:45am – 10:50am
Biomechanical Comparison of FiberLoop versus Looped Supramid Extra versus Ethibond Suture in Zone II Flexor Tendon Repair Using a Cyclic Protocol
Institution where the work was prepared: The Cleveland Clinic, Cleveland, OH, USA
Joy V. Sharma, MD, MS; Ryan Milks, BSE; Kathleen A. Derwin, PhD; Peter J. Evans, MD, PhD;
Jeffery N. Lawton, MD
*10:20am – 10:25am
Does Delayed Fixation of Non-Displaced Scaphoid Fractures
Affect Union Rate
Institution where the work was prepared: Naval Medical Center San Diego, San Diego, CA, USA
Nathan Hammel, MD; Leo Kroonen, MD; Eric Venn-Watson, MD; Edton Ganal, MD; Brian
Fitzgerald, MD; Eric Hofmeister, MD; Michael Thompson, MD, PhD
10:50am – 10:55am
Indications and Clinical Experience Using Adhesion Barrier Wrapping
Institution where the work was prepared: Miami Hand Center, Miami, FL, USA
Alejandro Badia, MD, FACS
10:25am – 10:30am
Discussion
Moderators: Dean Sotereanos, MD and Mary Nordlie, MS, OTR, CHT
10:55am – 11:00am
Discussion
*10:30am – 10:35am
Patterns of Upper Extremity Injury in Operation Iraqi Freedom
Institution where the work was prepared: Naval Medical Center, San Diego, CA, USA
Leo T. Kroonen, MD; Kevin Kuhn; Anatoly Hernandez
9:30am - 11:00am
CONCURRENT SCIENTIFIC PAPER SESSION A-2
Moderators: Robert Medoff, MD and William Geissler, MD
10:35am – 10:40am
Wrist and DRUJ Arthroscopy Findings in Distal Radius Fractures: Treatment
and Frequency of Ulnar Styloid Process Fractures and Triangular
Fibrocartilage Complex (TFCC) Injuries
Institution where the work was prepared: Yukihiko Obara, Tokyo, Japan
Yukihiko Obara; Eiko Yamabe, MD; Astuo Kawakita
9:30am – 9:35am
Intramedullary Fixation of Displaced Distal Radius Fractures
Institution where the work was prepared: Temple University Hospital, Philadelphia, PA, USA
Asif M. Ilyas, MD; Joseph J. Thoder, MD
10:40am – 10:45am
Biomechanical Analysis of an Air-Cell Equipped Plastic Splint (Aircast)
Versus Conventional Plaster Splint in a Distal Radius Fracture Model
Institution where the work was prepared: Mayo Clinic , Rochester, MN, USA
Shian Chao Tay, MD, MS; Kristin Zhao; Kai-Nan An; William P. Cooney
9:35am – 9:40am
Comparison of AO Type B and Type C Volar Shearing Fractures
of the Distal Radius
Institution where the work was prepared: Massachusetts General Hospital, Boston, MA, Tuvalu
Jesse Jupiter; J. Sebastiaan Souer; David Ring
10:45am – 10:50am
Does Vacuum Assisted Wound Closure Affect Tissue Pressures Following
Forearm Fasciotomy for Compartment Syndrome? A Cadaver Model
Institution where the work was prepared: William Beaumont Hospital, Royal Oak, MI, USA
Rachel S. Rohde, MD; Nicholas J. Cook, MD; Gregory V. Sobol, MD
9:40am – 9:45am
Distal Radius Fractures Treated with Multiplanar Cross Pin Fixation and a Low
Profile Non-Bridging External Fixator; the CPX System
Institution where the work was prepared: Ather Mirza, MD, Smithtown, NY, USA
Ather Mirza, MD
*10:50am – 10:55am
A New Test for Evaluating Acute Ulnar Collateral Ligament Injuries
of the Thumb
Institution where the work was prepared: University of New Mexico Medical School,
Albuquerque, NM, USA
Deana Mercer, MD; John Veitch, MD; Keikhosrow Firoozbakhsh, PhD; Amanda Medoro, MS;
Alicia Lacovara, BS
9:45am – 9:50am
Treatment of Distal Radius Fractures Using a Radial Stabilization Locking Plate
Institution where the work was prepared: Texas Tech University Health Science Center, El Paso, TX,
USA
Miguel Pirela-Cruz, MD; David Esquivel, ORT
10:55am – 11:00am
Discussion
*9:50am – 9:55am
A Prospective Randomized Clinical Trial of Unstable Distal Radius Fractures
treated with External Fixation, Radial Column Plating, or Volar Plating
Institution where the work was prepared: New York Orthopaedic Hospital, Columbia University
Medical Ctr, New York City, NY, USA
David H. Wei, MSc; Noah M. Raizman, MD; Clement J. Bottino, MD; Charles M. Jobin, MD;
Robert J. Strauch, MD; Melvin P. Rosenwasser, MD
11:15am – 12:00pm
9:55am – 10:00am
Discussion
Presidential Address
Scott H. Kozin, MD
The Power of Pinch
Moderators: David Bozentka, MD and M. Ather Mirza, MD
Pinch is a powerful form of expression and prehension.
Pinch allows us to manipulate our environment and perform activities of daily living. Able bodied persons take
pinch for granted. Children born congenital differences
and adolescents suffering trauma often lose their ability
to pinch and grasp. Loss of pinch creates considerable
dependence and loss of self-esteem. Many children and
adolescents can adapt using a variety of altered prehensile patterns to accomplish pinch. However, countless require surgery to achieve pinch, improve function,
and decrease dependence upon others. Surgeons have
spent careers devoted to the development of techniques
for restoration of pinch. This presidential address will
discuss pinch with a focus on its importance, surgical
procedures to regain pinch, and outcomes with regard
to quality of life and patient/surgeon satisfaction.
10:00am – 10:05am
Minimally Invasive Osteosynthesis (MIO) for Asian Osteoporotic Distal
Radius Fractures with Small Intramedullary Nail
Institution where the work was prepared: Komaki City Hospital, Komaki, Japan
Naoya Takada
10:05am – 10:10am
The effect of an unrepaired ulnar styloid base fracture on outcome
after operative treatment of a distal radius fracture
Institution where the work was prepared: Massachusetts General Hospital, Boston, MA, USA
Jesse Jupiter; David Ring; J Sebastiaan Souer
29
12:00pm – 1:15pm
Keynote Speaker & Book Signing (spouses welcome)
110 Pediatric Brachial Plexus Injury
Diagnosis and management of birth-related brachial plexus injury will
be the focus this course, including both early never reconstruction procedures and later orthopedic/hand surgery options.
Supported by:
Allen T. Bishop, MD, Moderator
Howard Clarke, MD
Scott Kozin, MD
Daniel Gottlieb, PhD
The Art of Caring
111 Scaphoid Fractures & Nonunions:
Arthroscopic, Percutaneous, Re-vascularization
All humans ultimately want to love and be loved, the want to feel their lives
have meaning and they want the security knowing that they are part of something bigger than themselves. Too often we pursue these goals through overachievement. Surprisingly, love, security and meaning can all be discovered by
making the choose one through which we see our lives much wider.
Daniel Gottlieb began his practice as a psychologist and family therapist in
1969 after receiving undergraduate and graduate degrees from Temple
University. As a young psychologist, working in the addictions field, he was
enjoying his professional successes and his two young daughters.
In 1979, while preparing a surprise for his wife on their 10th anniversary,
Gottlieb was in a near-fatal automobile accident, which left him paralyzed
from the chest down. Over the ensuing years, he faced depression, divorce
and the death of his wife, sister and parents. Throughout all, he maintained his
devotion to family and his career. Now, he sits in a wheel-chair observing life
and gaining unusual insight into what it means to the human.
Since 1985, Daniel Gottlieb has been hosting “Voices in the Family,” an
award-winning mental health call-in radio show aired on WHYY 90.9 FM,
Philadelphia’s local public radio station.
1:15pm – 1:30pm
Three surgeons will present a variety of arthroscopically assisted/percutaneous fixation techniques for scaphoid fractures and stable
delayed unions and non unions. Both dorsal ad volar approaches
with a variety of different cannulated implants will be discussed.
Arthroscopic treatment of stable nonunion, even with moderate
degrees of cystic resorption will be presented, with emphasis on adjuvant bone grafting techniques utilizing cancellous graft and PDGF
gels. The speakers will also present their preferred vascularized bone
graft, for these scaphoids with an ischemic or avascular proximal pole.
T. Greg Sommerkamp, MD, Moderator
Alexander Shin, MD
Joseph Slade, MD
112 Tendonitis, Tendonopathy, Tendon
Rupture About the Elbow
The elbow is plagued by tendonitis, tendonopathy, and tendon rupture.
Lateral and medial epicondylitis are difficult to treat and modalities will
be discussed in detail with an emphasis on efficacy. The treatment of
biceps and triceps ruptures will also be discussed. The controversy
regarding timing, surgical method, and rehabilitation will be addressed.
Andrew W. Gurman, MD, Vice Speaker
AMA House of Delegates
Peter Evans, MD, PhD
Jeff Greenberg, MD
Scott Steinman, MD
3:00pm – 5:00pm
Supported by:
Andrew W. Gurman, MD, an orthopaedic hand surgeon from Altoona,
Pa., was re-elected vice speaker of the American Medical Association
(AMA) House of Delegates in June 2008. He is a delegate from Pennsylvania
and has been a member of the Pennsylvania delegation for 16 years.
Dr. Gurman currently serves on both the AMA Board of Trustees (BOT) Audit
and the AMA-BOT Awards and Nominations committees, as well as on the Task
Force on Quality, Safety and Electronic Health Records. He also serves as board
liaison to the Advisory Committee on Gay, Lesbian, Bisexual and Transgender
Issues and serves as an AMA BOT representative on the AMA Foundation
board of directors.
Dr. Gurman previously served as the speaker and vice speaker of the House of
Delegates of the Pennsylvania Medical Society (PMS), and was also a member
of its board of trustees and executive board. He has presided over reorganization of the PMS House of Delegates meeting and streamlined the business of its
House.
Dr. Gurman twice served as chairman of PAMPAC, the political action committee of the PMS. He has served on the PMS council on governmental relations
(legislation) and has served on the council on legislation of the American
Society for Surgery of the Hand. A native of New York City, Dr. Gurman grew
up in Mount Vernon, N.Y. He attended Syracuse University and received his
MD degree from the State University of New York Upstate Medical University,
Syracuse, in 1980. He served his surgical internship and orthopaedic residency at the Montefiore Hospital/Albert Einstein Hospitals in the Bronx, N.Y., and
completed his fellowship in hand surgery at the Hospital for Joint Diseases
Orthopaedic Institute in New York City.
Dr. Gurman is now in private practice in Altoona. Starting as a solo practitioner,
he led his group to become a multi-specialty musculoskeletal organization. He
has served as chair of the Altoona Hospital bylaws committee and orthopaedic
surgery peer review committee, as well as chief of the orthopaedic service.
Dr. Gurman is a past president of the Blair County Medical Society. He has
served as professional chair for the United Way campaign, and he has also
been a member of the board of trustees of the Altoona Symphony Orchestra.
Dr. Gurman resides in Hollidaysburg, Pa., with his wife, Nancy. They have
two grown children.
1:30pm – 2:30pm
BC-1 Endoscopic Cubital
Tunnel Release
This workshop will feature a review of published literature and outcomes for
endoscopic cubital tunnel release along with indications, contraindications
and complications. The surgical technique for performing an endoscopic
cubital tunnel release will be reviewed using a unique system to facilitate the
procedure. The clinical history of the endoscopic cubital tunnel release procedure will also be examined. The Endoscopic Cubital Tunnel Release workshop will benefit surgeons interested in cubital tunnel release using an innovative endoscopic system as well as surgeons currently performing open or
endoscopic cubital tunnel release procedures.
Tyson Cobb, MD
Supported by:
BC-2 Avoiding Problems with
Distal Radius Fixation
Simple fixation of olecranon fractures and new concepts in scapholunate
instability.
Miguel Pirela-Cruz, MD
A. Lee Osterman, MD
Mark Rekant, MD
Rob Medoff, MD
Supported by:
BC-3 Surgical Tips in Treating
Distal Radius Fractures
Lecture and Cadaveric demonstration showcases surgical tips and
techniques using Medartis watershed line adaptive distal radius plate with
polyaxial locking screws.
Jaiyoung Ryu, MD
3:30pm – 4:30pm
108
Nerve transfers represent a considerable advancement in the treatment
of nerve injuries. Numerous transfers have been described for radial,
median, and ulnar injuries. This course will discuss those transfers,
including indications, technique, and outcome.
Susan MacKinnon, MD
Christine Novak, MS PT
Justin Brown, MD
Elbow Trauma and Coverage
This symposium will review treatment options for difficult soft-tissue coverage problems about the elbow, addressing large soft-tissue defects,
which cannot be treated with local random fasciocutaneous flaps or skin
grafts. This course will provide and algorithm for selecting treatment
options based on patient needs and available donor sites.
Milan Stevanovich, MD, Moderator
Stephen Trigg, MD
114 Burn Management
Burns remain a difficult management problem. The degree of burn dictates the management from observation to early excision. This course
will discuss the various treatment modalities to maximize outcome and
minimize scarring. In addition, established burns present with substantial
deformity and contracture. The reconstruction of these difficult problems
will be discussed along with case examples.
Roger Simpson, MD
Supported by:
Intercarpal Fusions: What Works and
What Does Not Work!
Intercarpal fusions remain a viable alternative to treat instability and/or
arthritis. There are a myriad of surgical methods to obtain an intercarpal
fusion. Despite recent implant advances, malunion and nonunion are
ongoing problems. This course will highlight what works and what does
not work including technical pearls to obtain union.
David Bozentka, MD
Steven Moran, MD
109
Additional CME 1 Credit each
113 Nerve Transfers for the Upper
Extremity -What Works
Instructional Courses - Additional CME 1 hour
107
Bioskills Courses - Additional CME 2 Credits
115 Financial Course - Life Financial
Goals for Physicians
Physicians and therapists are busy individuals that often lack the time to
do investment planning with a trusted advisor, and often get expensive
products without a proper plan. This discussion will address many of
the needs physicians and therapists have for investment planning to
help reduce income taxes, avoid costly pitfalls of insurance that many
physicians and therapists are sold, and effective techniques for building
retirement savings more quickly and safely. Also, we will discuss
alternative investment strategies to combat the dynamic everchanging
global economy.
Patrick R. Donnelly, CIMA - Smith Barney Consulting Group
Jeffrey M. Palmer - Smith Barney Consulting Group
Nerve Compression and Repair
Compressive neuropathies and nerve lacerations are frequent problems
treated by the hand surgeon. This course will discuss the rationale for
treatment of compressive neuropathies and highlight preferred techniques.
Advances in nerve repair will also be discussed included fibrin glue and
methods for better coaptation.
John Taras, MD, Moderator
Jeff Yao, MD
Robert Spinner, MD
30
DAY-AT-A-GLANCE
Friday, January 9, 2009
6:00am – 5:00pm
Speaker Ready Room
Silversword
6:00am – 12:00pm
AAHS Poster Viewing
6:30am – 6:00pm
Meeting Services
6:30am – 7:30am
116 Humanitarian Care in a Combat Arena
117 Peripheral Nerve Repair and Reconstructive-Glue Tubes, etc.
118 PIP Joint - Update on Replacement & Condylar Replacement Techniques
119 Radial Head Repair vs. Replacement
120 Ulnar Sided Wrist Update
121 Wound Coverage: Kids to Adults
Pikake 2 & 3
IIima 2 & 3
Maile 2 & 3
Hibiscus 3
Hibiscus 1 & 2
Plumeria 2 & 3
7:00am – 8:00am
Coffee with Exhibitors
Haleakala Gardens
7:45am – 9:15am
Concurrent Scientific Paper Session B-1
Concurrent Scientific Paper Session B-2
Haleakala 1
Haleakala 2 & 3
8:35am – 9:35am
PANEL: Cubital Tunnel: Defend Your Operation
Haleakala 1
9:15am – 9:45am
Breakfast with Exhibitors
Haleakala Gardens
9:45am – 10:45am
Panel: How to Maximize Reimbursement in Practice
Haleakala 1
10:45am – 11:15am
Joseph Danyo Invited Speaker:
Louis L. Carter, Jr. MD, FACS
Haleakala 1
11:15am – 12:00pm
Panel: Update on Nerve Reconstruction
Haleakala 1
12:00pm – 12:30pm
Break with Exhibitors
Haleakala Gardens
12:00pm – 12:30pm
Annual Business Meeting (AAHS Members Only)
Haleakala 1
12:30pm – 5:45pm
Comprehensive Hand Surgery Review Course
Haleakala 2 & 3
12:45pm – 2:45pm
AAHS Board of Directors Luncheon
Illima 2 & 3
3:10pm – 3:30pm
Haleakala Gardens
4:00pm – 5:00pm
Hand Surgery Endowment Board of Governors Meeting
Illima 2 & 3
7:00pm – 10:00pm
AAHS Awards Dinner/Dance
Chapel Lawn
31
AAHS: Friday, January 9, 2009
8:00am – 8:05am
Mirza Single-Portal Endoscopic Carpal Tunnel Release
A Prospective, Randomized Study
Institution where the work was prepared: Beth Israel Deaconess Medical Center, Boston, MA, USA
Abigail Zamora, BA; Charles S Day, MD; Albert Yeh, BA; Miguel Ramirez, MD
Supported by:
6:00am – 7:45am
Coffee
6:00am – 12:00pm
AAHS Poster Viewing
6:30am – 7:30am
Instructional Courses - Additional CME 1 Credit each
8:05am – 8:10am
The 6-item CTS Symptoms Scale - A Brief Outcomes Measure for
Carpal Tunnel Syndrome
Institution where the work was prepared: Department of Orthopedics Hässleholm-Kristianstad,
Hässleholm, Sweden
Isam Atroshi, MD, PhD; Per-Erik Lyrén, MSc; Christina Gummesson, PT, PhD
116 Humanitarian Care in a Combat Arena
As the Global War on Terrorism continues, US medical facilities have
taken on the responsibility of providing more comprehensive medical
care as the host nation medical infrastructure gradually recovers.
Emergent, urgent, and in some circumstances, routine medical care are
frequently provided to local nationals, civilian contractors, host and unified Security Forces and detainees. Humanitarian, medical outreach
programs are integrated into the strategic mission. The many advantages, challenges, potential negative ramifications, and situational
requirements against a backdrop of shifting military and political frameworks will be discussed and several illustrative cases presented.
Eric Hofmeister, MD, Moderator
Gregory Hill, MD
8:10am – 8:15am
Discussion
Moderators: Christine Novak, PT, MS, PhD (c) and Nash Naam, MD
*8:15am – 8:20am
Early Clinical Outcomes with the Use of Decellularized Nerve
Allograft for Repair of Sensory Defects within the Upper Extremity
Furkan Erol Karabekmez, MD; Ahmet Duymaz, MD; Samir Mardini; Steven L. Moran
117 Peripheral Nerve Repair and Reconstruction Glue, Tubes, etc.
Recent advancements in peripheral nerve repair and reconstruction
have focused on the use of nerve conduits and fibrin glue. However,
do these modalities enhance outcome? This course will address this
question with a focus on uses and abuses of these advancements.
Susan MacKinnon, MD, Moderator
John Taras, MD
Allen Van Beek, MD
*8:20am – 8:25am
Effect of profession on duration of symptoms prior to carpal tunnel
release surgery
Institution where the work was prepared: Beth Israel Deaconess Medical Center, Harvard
Medical School, Boston, MA, USA
Eric Makhni; Charles S. Day
118 PIP Joint - Update on Replacement &
Condylar Replacement Techniques
This course will cover difficult fracture/dislocations of the PIP joint and
management of some with the HHRA, and the CRA. Reconstructive
techniques with prosthetic arthroplasty such as the various SRA implants
will be presented as well.
T. Greg Sommerkamp, MD, Moderator
Peter Murray, MD
Kevin Chung, MD
*8:25am – 8:30am
Comparison of Anterior Transposition and In Situ Decompression for
Ulnar Nerve Compression at the Elbow: One Surgeon’s Experience
Institution where the work was prepared: Johns Hopkins University School of Medicine,
Baltimore, MD, USA
Ron Gutmark, BA; Elizabeth N. Le, BS; E. Gene Deune, MD
119 Radial Head Repair vs. Replacement - Why,
When & How!
8:30am – 8:35am
Revision Surgery after Carpal Tunnel Release Using Fascio-Cutaneous
Island Flaps
Institution where the work was prepared: University Hospital Bern, Bern, Switzerland
Matthias Traub, MD; Esther Voegelin
Radial head fractures can occur in isolation or with associated injuries
about the elbow and forearm. Treatment depends upon the fracture pattern and associated injuries. This course will discuss methods for radial
head fixation including approach and fixation devices. In addition, the
role of radial head replacement will be discussed in detail.
Mark Baratz, MD, Moderator
120 Ulnar Sided Wrist Update - Sauve,
Darrach, U-Head
8:35am – 8:40am
Application of Fibrin Glue in Microvascular Anastomoses: Comparative
Analysis with the Conventional Suture Technique Using a Free Flap Model
Institution where the work was prepared: Instituto de Ortopedia e Traumatologia da USP, São
Paulo, Brazil
Alvaro B. Cho, MD; Mattar Júnior Rames
Ulnar sided wrist pathology is common and the treatment algorithm
for degenerative disease and/or instability remains elusive. This
course will discuss the role of Darrach resection, the Suave-Kapandji
technique, and replacements techniques. The respective indications
will be highlights and surgical pearls provided. Cases will be included as part of the learning experience.
Kevin Renfree, MD
Luis Scheker, MD
Joseph Slade, MD
Dean Sotereanos, MD
8:40am – 8:45am
Discussion
Moderators: Keith Brandt, MD and Amit Gupta, MD
121 Wound Coverage: Kids to Adults
This course will help the practicing hand surgeon develop an algorithm for confidently approaching wounds of the hand and upper
extremity. The session will present a practical and systematic
approach to the evaluation and treatment of wounds of the hand
and upper extremity based on the “reconstructive ladder” updated
with current techniques. Pearls and technical tips from 3 experienced
surgeons will be presented as well as a panel discussion that will
encourage audience participation.
Nicholas Vedder, MD, Moderator
Benjamin Chang, MD
Anthony Smith, MD
*8:45am – 8:50am
Pedicled Descending Branch Muscle-sparing Latissimus Dorsi Flap
for Trunk and Upper Extremity Reconstruction
Institution where the work was prepared: UT Southwestern Medical Center, Dallas, TX, USA
Corrine Wong, MBBS, MRCS; Michel Saint-Cyr, MD
*8:50am – 8:55am
Forearm Osseous Reconstruction with Vascularized Free Fibula Grafts
Brian T. Carlsen, MD; Scott Thompson, BA; Steven L. Moran, MD; Allen T. Bishop, MD;
Alexander Y. Shin, MD
7:45am - 9:15am
CONCURRENT SCIENTIFIC PAPER SESSION B-1
Moderators: Eduardo Gonzalez, MD and James Chang, MD
*8:55am – 9:00am
Intravascular Stenting Method for Fingertip Replantation
Institution where the work was prepared: Narushima Mitsunaga, tokyo, Japan
Jun Araki; Narushima Narushima, MD
7:45am – 7:50am
Treatment of Symptomatic Neuromas of the Dorsal Radial Sensory Nerve
Using a Resorbable Nerve Conduit
Institution where the work was prepared: Thomas Jefferson, Philadelphia, PA, USA
A. Lee Osterman, MD; Sergio Rodriguez; John Taras
*9:00am – 9:05am
Triangular Flaps: a Modified Technique for the Correction of Congenital
Constriction Ring Syndrome
Institution where the work was prepared: Chang Gung Memorial Hospital, Kaohsiong, Taiwan
Lynn PL Tan, MBBS, MRCS, MMed; Yuan-Cheng Chiang, MD
7:50am – 7:55am
Intra- and Inter-Examiner Variability in Performing Tinel’s Test
Institution where the work was prepared: Union Memorial Hospital, Baltimore, MD, USA
Kenneth R. Means, MD; Eric H. Williams, MD; Scott Lifchez, MD; Reg Dunn; A. Lee Dellon,
MD, PhD
9:05am – 9:10am
Patient Reported Outcome Following a Traumatic Peripheral Nerve Injury
Institution where the work was prepared: University of Toronto and York University, Toronto,
ON, Canada
Christine B. Novak, PT, MS, PhD(c); Dimitri J. Anastakis, MD; Dorcas E. Beaton, PhD; Joel
Katz, PhD
*7:55am – 8:00am
Outcomes of Single versus Double Nerve Transfers for Elbow Flexion
Brian T. Carlsen, MD; Michelle Kircher; Robert J. Spinner; Allen T. Bishop; Alexander Y. Shin
9:10am – 9:15am
Discussion
32
7:45am - 9:15am
CONCURRENT SCIENTIFIC PAPER SESSION B-2
Moderators: Ronald Palmer, MD and Sharon Dest, PT, CHT
8:50am – 8:55am
Line Scan Diffusion Spectrum of Rat Denervated Skeletal Muscle
Institution where the work was prepared: HIratsuka City Hospital, HIratsuka City, kanagawa, Japan
Eiko Yamabe, MD; Toshiyasu Nakamura, MD, PhD; Yukihiko Obara, MD; Koji Abe, MD
7:45am – 7:50am
Arthroscopic Transosseous Repair of the Ulnar Disruption of the
TFCC to the Ulnar Fovea
Institution where the work was prepared: Department of Orthopaedic Surgery, Keio University,
Tokyo, Japan
Toshiyasu Nakamura, MD, PhD; Kazuki Sato, MD, PhD; Masato Okazaki, MD; Yoshiaki
Toyama, MD, PhD; Hiroyasu Ikegami, MD, PhD
8:55am – 9:00am
Anatomical Features of the Pronator Quadratus muscle for the treatment of
Distal Radius Fractures with a Palmar Locking Plate - Cadaveric Study
Naoya Takada
*9:00am – 9:05am
Profit Margins for Inpatient and Outpatient Orthopedic Procedures:
a Comparative Study
Institution where the work was prepared: Beth Israel Deaconess Medical Center, Harvard
Medical School, boston, MA, USA
Eric Makhni; Charles S. Day
7:50am – 7:55am
Efficacy and Safety of Clostridial Collagenase for Injection in Patients
with Dupuytren’s Contracture: Results of a Phase III Trial
Institution where the work was prepared: Indiana Hand Center, Indianapolis, IN, USA
F. Thomas D. Kaplan, MD; Bronier L. Costas, MD; Vincent R. Hentz, MD; Lawrence C. Hurst;
John Lubahn
7:55am – 8:00am
Treatment of Scaphoid Nonunions Using Vascularized Bone Grafts
Transplanted Through a Dorsal Approach
Institution where the work was prepared: Kyoto University Hospital, Kyoto, Japan
Ryosuke Kakinoki, MD, PhD; Ryosuke Ikeguchi; Takashi Nakamura; Taiichi Matsumoto, MD
9:05am – 9:10am
Modeling of Upper Extremity Problems
Institution where the work was prepared: University of Louisville, Louisville, KY, USA
Steven J. McCabe, MD, MSc; Stephanie Tapp
8:00am – 8:05am
Underutilization of Upper Extremity Reconstruction for Persons with
Tetraplegia: The Patient Perspective
Institution where the work was prepared: Rehabilitation Institute of Chicago, Chicago, IL, USA
Michael S. Bednar, MD; Rebecca Ozzelie, OTR/L; Elizabeth Jordan, OTR/L, CHT
9:10am – 9:15am
Discussion
8:05am – 8:10am
The Point Prevalence Of The DRUJ Injuries Complicating Perilunate Injuries
Institution where the work was prepared: Kleinert Institute for Hand and Microsurgery,
Louisville, KY, USA
Tuna Ozyurekoglu, MD; Paolo Sassu; Sandy Hanlin
9:15am – 9:45am
9:45am – 10:45am
Panel: How to Maximize
Reimbursement in Practice
The course will present strategies for maximizing efficiency
and reimbursement in private hand surgery practices. The
presenters will discuss their experiences and the current state
of opportunities and regulations regarding non-clinical
sources or revenue, as well as maximizing reimbursement for
clinical practice activities in today's challenging practice environment.
Kyle Bickel, MD, Moderator
Steve Leibovic, MD
Daniel Nagle, MD
8:10am – 8:15am
Endoscopic Cubital Tunnel Recurrence Rates
Institution where the work was prepared: Orthopaedic Specialists, Davenport, IA, USA
Tyson Cobb, MD; Patrick T. Sterbank, PA-C; Jon Lemke, PhD
8:15am – 8:20am
Discussion
10:45am – 11:15am
Moderators: William Dzwierzynski, MD and Leonard Bodell, MD
*8:20am – 8:25am
Outcome Following Acute Primary Darrach Resection for Comminuted
Fractures of the Distal Ulna at the time of Operative Fixation of Unstable
Fractures of the Distal Radius
Institution where the work was prepared: New York University Hospital for Joint Diseases, New
York, NY, USA
David E. Ruchelsman, MD; Keith B. Raskin, MD; Michael E. Rettig, MD
Joseph Danyo Invited Speaker
Louis L. Carter, Jr. MD, FACS
Caring for the Disabled and Deformed in
the Emerging World - What a Privilege!
Dr. Carter will discuss the experiences of a plastic and hand surgeon in full-time missionary volunteer service over twenty-five years.
The experiences of a plastic and hand surgeon in full-time missionary volunteer service over twenty-five years. Between
1987 and 1995 Dr. Louis L. Carter made several trips to
work and teach at remote mission hospitals. In 1996, he
returned to full-time missionary service with SIM. Since then he
has visited 25 different mission hospitals in 20 countries on 63
overseas trips in a ministry called, “Home Schooling for
Missionary and National Doctors.” His trips average two
months each, and he teaches the local missionary and national doctors plastic and hand surgery and operating room nursing as well as take much needed books, equipment and instruments so that doctors can continue to perform the techniques
they have been taught.
8:25am – 8:30am
Low Calcaneal Bone Mineral Density is Associated with a High Risk to
Sustain a Distal Radius Fracture – a Population-Based Study
Institution where the work was prepared: Department of Orthopedics Hässleholm-Kristianstad,
Hässleholm, Sweden
Isam Atroshi, MD, PhD; Fredrik Åhlander, MD; Mats Billsten; Henrik G. Ahlborg, MD, PhD;
Dan Mellström, MD, PhD; Claes Ohlsson, MD, PhD; Östen Ljunggren, MD, PhD; Magnus K.
Karlsson, MD, PhD
8:30am – 8:35am
Clinical and Radiographic Outcomes Following Utilization of
Purpose-Designed Threaded Pins for the Treatment of Extraarticular
Institution where the work was prepared: The Philadelphia Hand Center, PC, Philadelphia, PA, USA
John S. Taras, MD; Joshua Abzug, MD
11:15am – 12:00pm
8:35am – 8:40am
Outcome of Nonoperative Treatment of Ulnar-Sided Wrist Pain
Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh,
PA, USA
Robert Joseph Goitz, MD; Ali Razfar; John M. Duffy, PAC; Robert Alexander Kaufmann, MD;
Deborah Kowalchuk; James Irrgang; Camilo D. Borrero; Jeffrey D. Towers
Panel: Update on Nerve
Reconstruction - Grafts, Transfers,
Glue, Transfers
A nerve injury requires reconstruction. There are a multitude
of options including the use of grafts, nerve transfers, conduits, and fibrin glue. The appropriate choice can be difficult.
This panel will attempt to clarify the use of each technique
with regards to indications, contraindications, and outcome.
Case presentation will be utilized to stimulate discussion.
Susan Mackinnon, MD, Moderator
Alexander Shin, MD
Thomas Trumble, MD
8:40am – 8:45am
Discussion
Moderators: Steven J. McCabe, MD and Kenneth Marshall, MD
8:45am – 8:50am
Baseline Characteristics of Patients Enrolled in Two Phase III
Studies of Injectable Clostridial Collagenase for Dupuytren’s Contracture
Institution where the work was prepared: The Indiana Hand Center, Indianapolis, IN, USA
F. Thomas D. Kaplan, MD; Marie Badalamente, PhD; Robert N. Hotchkiss, MD; John D.
Lubahn, MD; Stephen Coleman, MD; Stephen Hall, MD
12:00pm – 12:30pm Annual Business Meeting (AAHS Members only)
12:45pm – 2:45pm
33
AAHS Board of Directors Luncheon
12:30pm – 5:45pm
3:30pm – 3:50 pm
Comprehensive Hand Surgery
Review Course - Additional CME 5.0 Credits
The faculty of this Comprehensive Hand Surgery Review
Course will address the important topics covered on board
examinations, the hand surgery certification examination
and resident in-training examinations. From arthrogryposis
to Z-plasty, this course will truly have it all and you will consider it time well spent.
Jeffery Friedrich, MD
Steven L. Moran, MD, Chairman
$100. Additional Registration Required. Box lunch will be served.
3:50pm – 4:05pm
12:30pm – 12:50pm Tendonopathies and Dupuytrens Contracture
Tendonopathies of the hand and wrist and Dupuytrens
Contracture are among the most common problems seen in
hand surgery. An overview of the pathophysiology of these
conditions will be provided as well as specific treatment
recommendations.
4:05pm – 4:25pm
12:50pm – 1:10 pm Compressive Neuropathies & CRPS
In this lecture carpal tunnel syndrome and cubital tunnel syndrome will be reviewed. Physical examination and diagnostic modalities will be emphasized. The last portion of the
presentation will review the diagnosis, treatment and longterm sequelae of complex regional pain syndrome.
4:25pm – 4:45pm
4:45pm – 5:00pm
5:00pm – 5:20pm
The diagnosis and management of distal radius fractures
will be reviewed. Specific attention will be given to outcome
based research in determining the best treatment for specific
fracture types. Finally a review of malunion management
will be provided.
5:20pm – 5:40pm
Distal Radioulnar Joint
A comprehensive review of adult distal radius fractures
including the clinical evaluation, diagnostic imaging
options and interpretation, indications for operative versus
non-operative treatment and the current strategies and indications for the various operative treatment techniques.
4:00pm – 5:00pm
Scaphoid Fractures and
Non-Unions, Kienbocks Disease
A review of the clinical features, diagnostic challenges, operative and non-operative treatment options, and a contemporary approach to the patient with an acute scaphoid fracture
or established non-union. The talk will also provide an
overview to the diagnosis and treatment of Kienbock’s disease
Hand Surgery Endowment Board of
Governors Meeting
7:00pm – 10:00pm AAHS Awards Dinner/Dance
Jimmy Mac and the Kool Kats
Carpal Instability, Wrist Arthritis
A review of the anatomy and mechanics of the wrist as it
relates to carpal instability, including a review of the diagnostics and treatment of common patterns of instability.
This talk will also review the common patterns of wrist
arthritis which develop from long-standing carpal instability
and their management.
Steven L. Moran, MD
Fractures of the Metacarpals and Phalanges
Metacarpal and phalangeal fractures are among the most
common injuries seen in the hand. A thorough review of
the anatomy and biomechanics of these injuries will be
provided. The treatment choices of closed management,
percutaneous pinning, plate fixation and intramedullary
rodding will be reviewed along with their technical
nuances.
Brian Carlsen, MD
3:10pm - 3:30pm
Vascular Disorders of the
Hand/Reimplantation
Vascular disorders of the hand are uncommon and the indications for reimplantation narrow. This presentation will discuss the various diagnostic and treatment challenges
encountered in vascular disorders of the hand. Techniques
and indication for reimplantation will be reviewed.
Peter M. Murray, MD
Alexander Y. Shin, MD
2:50pm – 3:10pm
Tendon Transfers for the Hand
Palsy of the median, ulnar or radial nerves can be devastating to hand and wrist function. Tendon transfers can provide predictable restoration of function. The more commonly chosen tendon transfers will be discussed along with the
technical challenges unique to each set of transfers.
Doug Sammer, MD
Brian Adams, MD
2:30pm – 2:50pm
Soft Tissue Coverage in the Hands
A variety of pedicled flaps and free flaps of are available
for coverage of the soft tissue defects of the hand. These
flaps will be reviewed and technical tips provided. A spectrum of cases will be reviewed to illustrate the utility of each
soft tissue coverage procedure.
David Dennison, MD
2:10pm – 2:30pm
Tumors of the Hand and Wrist
This talk will discuss the pathology, radiology and treatment
of benign and malignant bone and soft tissue tumors affecting the hand and wrist.
Carol Morris, MD
Thumb Basal Joint Arthritis and
Inflammatory Arthritis
This lecture will address the fundamentals of diagnosis and
treatment for thumb basal joint arthritis, as well as an
overview of rheumatoid arthritis and inflammatory arthritis of
the hand and wrist. Critical success factors necessary to
obtain favorable outcomes will be emphasized.
Marco Rizzo, MD
1:50pm – 2:10pm
Congenital Hand Differences
This talk will review congenital anomalies of the upper
extremity including the embryology, diagnosis, and treatment of these deformities. Associated syndromes will be
reviewed, along with long-term outcomes, and complications of specific congenital anomalies.
Steven L. Moran, MD
Robert Spinner, MD
1:30pm – 1:50pm
Infections of the Hand
Comprehensive review of infections of the hand with up to
date information to allow the participant to feel comfortable
treating patients with these maladies.
Kevin D. Plancher, MD, MS, FACS, FAAOS
Jennifer M. Wolf, MD
1:10pm – 1:30pm
Flexor & Extensor Tendon Injuries
This presentation will review the physical exam of extensor
and flexor tendon injuries. The technical aspects of extensor
and flexor tendon repairs will be discussed as well as the biomechanical rationale behind the development of current post
op rehab protocols. The basic science of tendon healing will
be outlined.
34
AMERICAN SOCIETY FOR PERIPHERAL NERVE
AMERICAN SOCIETY FOR RECONSTRUCTIVE MICROSURGERY
DAY-AT-A-GLANCE
Saturday, January 10, 2009
6:00am – 4:00pm
Speaker Ready Room
Silversword
6:30am – 5:00pm
Meeting Services
6:45am – 8:15am
Coffee
IIima
7:00am – 8:00am
AAHS/ASPN/ASRM Instructional Courses
201 Pedicled and Free Flap Reconstruction for Trauma
and Tumors of the Upper Extremity
202 Current State of the Art Toe Transfers for Thumb
and Finger Reconstruction
203 Introduction to Acupuncture
204 Multiple Nerve Transfers for Control of Upper Extremity
Myoelectric Prostheses
205 Bridging the Nerve Gap
206 Brachial Plexus Surgery - What Works and What Does Not Work
IIima 2 & 3
Maile 2 & 3
7:45am – 8:30am
Haleakala Gardens
8:15am – 8:30am
AAHS/ASPN/ASRM Presidents’ Welcome
Haleakala 1
8:30am – 9:30am
PANEL: Crisis in Hand Trauma Coverage
Haleakala 1
9:30am – 10:00am
AAHS/ASPN/ASRM Breakfast with Exhibitors
Haleakala Gardens
10:00am – 11:00am
PANEL: Medical Diplomacy - Volunteering,
Training and the Military
Haleakala 1
11:00am – 12:00pm
AAHS/ASPN/ASRM Presidents Invited Lecturer:
Graham Gumley, MD
Haleakala 1
12:00pm
AAHS/ASRM Golf Tournament:
Wailea Country Club
12:00pm – 5:00pm
ASRM Master Series
Haleakala 1
12:00pm – 3:00pm
ASPN Programming
Haleakala 4 & 5
6:00pm – 8:00pm
ASPN/ASRM Welcome Reception
Molokini Gardens
35
Pikake 2 & 3
Plumeria 2 & 3
Hibiscus 1 & 2
Hibiscus 3
AAHS/ASPN/ASRM:
6:45am – 8:15am
Coffee
7:00am – 8:00am
AAHS/ASPN/ASRM Instructional Courses Additional CME 1 Credit each
9:30am – 10:00am
10:00am – 11:00am
AAHS/ASPN/ASRM PANEL: Medical DiplomacyVolunteering, Training, and the Military
Volunteering is a method of medical diplomacy. Many hand
surgeons volunteer their time to care for those in developing
countries. In addition, our military provides humanitarian efforts
across the globe. This panel will highlight those efforts and
emphasize the care, the relationships, and the good will
established during these outreaches.
Supported by:
Miguel Pirela-Cruz, MD, Co-Moderator
Eric Hofmeister, MD, Co-Moderator
Nash Naam, MD
201 Pedicled and Free Flap Reconstruction
for Trauma and Tumors of the Upper Extremity
Amit Gupta, MD
Joseph Upton, MD
202 Current State of the Art Toe Transfers
for Thumb and Finger Reconstruction
11:00am – 12:00pm
Gregory Buncke, MD
Neil F. Jones, MD
Fu Chan Wei, MD
203 Introduction to Acupuncture:
Principles and Applications
AAHS/ASPN/ASRM Presidents Invited Lecturer
Graham Gumley, MD
Helping Our Hands Restore Their Own Feeling
This lecture will introduce the participant to the art and basic science
of acupuncture. There will be opportunity to do hands on needling
techniques of some common acupuncture points.
Despite the pace of Globalization this young century, the poor
remain in the dark shadow of health care—not able to see
any advantage from our skills and developments. Sharing our
knowledge and teaching our skills in developing countries
multiplies our work, restores hope where the need is greatest
and returns to us the true satisfaction of our healing profession.
Dr. Gumley will give a talk based on his recent experiences in
the developing world with small teams of Hand and Upper
Limb Surgeons providing free care to the poor, with discussion
about the opportunities, challenges and rewards.
Lawrence J. Rossi Jr. MD, FAAP, DABMA
204 Multiple Nerve Transfers for Control
of Upper Extremity Myoelectric Prostheses
(Targeted Reinnervation)
This course will describe sets of nerve transfers to aid high upper
extremity amputees in the intuitive control of their myoelectric prostheses. The surgical procedures, illustrative cases, and outcomes
will be presented.
Greg Dumanian, MD
12:00pm
AAHS/ASRM Golf Tournament
Wailea Country Club: Gold Course
12:00pm – 5:00pm
ASRM Master Series
12:00pm – 3:00pm
ASPN Programming
6:00pm – 8:00pm
A nerve gap after injury or tumor is a vexing problem. The gap can
be bridged by graft material or conduit. In addition, the gap can be
bypassed by adjacent nerve transfer. The decision making process is
complicated and this panel will specifically address this issue. The
role of grafting, conduits, and transfers will be discussed in detail.
James Chang, MD
Susan MacKinnon, MD
Allen Van Beek, MD
206 Brachial Plexus Surgery-What Works and
What Does Not Work
Brachial plexus reconstruction is a demanding procedure with the
goal of maximizing arm function after regeneration. However, the
number of viable axons may be limited and priority must be given
downstream to achieve optimum outcome. In addition, nerve transfers from within the plexus and outside the plexus can increase available axons. This course will critically evaluate the role of neurolysis,
nerve grafting, and nerve transfers in brachial plexus reconstruction.
Allen Bishop, MD
Robert Spinner, MD
8:15am – 8:30am
AAHS/ASPN/ASRM President’s Welcome
Scott H. Kozin, MD, AAHS President
Robert C. Russell, MD, ASPN President
Neil F. Jones, MD, ASRM President
8:30am – 9:30am
AAHS/ASPN/ASRM PANEL:
Crisis In Hand Trauma Coverage
L. Scott Levin, MD, FACS, Moderator
Neil F. Jones, MD
E. Anne Ouellette, MD
Luis Scheker, MD
36
Supported by:
DAY-AT-A-GLANCE
Friday, January 9, 2009
6:00am – 5:00pm
Speaker Ready Room
Silverswood
6:30am – 6:00pm
Meeting Services
8:30am – 11:00am
ASPN Council Meeting
IIima 2 & 3
11:30am – 12:00pm
Haleakala Gardens
12:00pm – 12:10pm
Presidents/Program Chair Welcome
Haleakala 4 & 5
12:10pm – 1:15pm
Scientific Paper Session A
Haleakala 4 & 5
1:00pm – 6:00pm
ASPN Poster Viewing
1:15pm – 2:15pm
ASPN Invited Speaker: Allan Belzberg, MD
Haleakala 4 & 5
1:15pm – 3:15pm
PANEL: Chronic Pain Management
Haleakala 4 & 5
3:15pm – 3:45pm
Haleakala Gardens
3:30pm – 5:00pm
Scientific Paper Session B
Haleakala 4 & 5
37
ASPN: Friday, January 9, 2009
*1:00pm – 1:05pm
Determining Cortical and Functional Deficits Following Partial
Transected Nerve Donation in a Rat Model Using fMRI
Institution where the work was prepared: Medical College of Wisconsin, Milwaukee, WI, USA
Seth Jones, MD; Rupeng Li; James Hyde; Hani Matloub; Ji-Geng Yan
8:30am – 11:00am ASPN Council Meeting
12:00pm – 12:10pm Presidents/Program Chair Welcome
*1:05pm – 1:10pm
Is Denervation Superior to Epicondylectomy?
Institution where the work was prepared: Southern Illinois University , Springfield, IL, USA
Nada Berry, MD; A. Lee Dellon, MD; Michael W. Neumeister; Robert C. Russell, MD, FACS
1:10pm – 1:15pm
Discussion
1:15pm – 2:15pm
Invited Speaker
Nash Naam, MD, ASPN Program Chair
12:10pm - 1:15pm
SCIENTIFIC PAPER PRESENTATIONS SESSION A
Moderators: Gregory Borschel, MD and Melanie Urbanchek, MD
Allan Belzberg, MD
Neuropathic Pain: From Bench to
Bedside and Back Again
Patients who suffer from neuropathic pain states can display
a variety of rather bizarre pain behaviors including mechanical hyperalgesia outside the area of injury. Transnational
research, moving back and forth from the laboratory and
bedside, has fostered an evolution of hypotheses modeling
how peripheral nerve injury can lead to neuropathic pain
states. In getting to the current knowledge base, this lecture
will also highlight the sometimes painful realities of hypothesis driven research.
12:10pm – 12:15pm
Impact of C7 Transection on the Upper Limb: Quantification of
Motor Function in a Rat Model
Huan Wang, MD, PhD; Anthony J. Windebank; Robert J. Spinner
*12:15pm – 12:20pm
Anatomic Study of Roos’ Type 3 Band and its Relationship to
the Lower Roots of the Brachial Plexus
Julia Spears, MD; Salim C. Saba, MD; David C. Kim, MD, FACS; Amitabha Mitra, MD;
Carson Schneck, MD, PhD
Allan Belzberg, MD completed his undergraduate and
graduate education at the University of British Columbia,
moving to the University of Calgary for medical school.
Internship was performed at McGill University and residency
completed back at the University of Calgary. He went on to
2 years of post graduate training at Johns Hopkins Hospital
as an R. Samuel McLaughlin Foundation scholar focusing on
pain physiology.
12:20pm – 12:25pm
Retroperitoneal Femoral Nerve Reconstruction in the Paediatric Population
Institution where the work was prepared: The Hospital for Sick Children and the University of
Toronto, Toronto, ON, Canada
Howard M. Clarke, MD, PhD, FRCS(C); Kim Tsoi; Bart M. Stubenitsky; Christine G. Curtis;
Justin T. Gerstle
Allan Belzberg is director of Peripheral Nerve Surgery at
The Johns Hopkins Hospital and is an Associate Professor of
Neurosurgery at the Johns Hopkins School of Medicine. His
clinical practice attracts patients from around the world. His
laboratory, funded by a DOD grant, is studying neuroma
formation.
*12:25pm – 12:30pm
The Case for Neuroma Resection: Recovery of Elbow Flexion after
Nerve Grafting in Obstetrical Brachial Plexus Palsy
Institution where the work was prepared: Children’s Healthcare of Atlanta, Atlanta, GA, USA
Thomas J. Moore, MD; Ann R. Schwentker, MD
12:30pm – 12:35pm
Nerve Transfers to Reanimate Elbow Flexion in Obstetric
Brachial Plexus Lesions
Institution where the work was prepared: Leiden University Medical Center, Leiden,
Netherlands
Willem Pondaag, MD; Martijn J.A. Malessy, PhD
2:15pm – 3:15pm
12:35pm – 12:40pm
Discussion
3:15pm – 3:45pm
12:40pm – 12:45pm
The Evaluation of Sensory Function for the Patients of
Suprascapular Nerve Palsy
Institution where the work was prepared: Dept. of Orthop. Surg., School of Medicine, Keio
University, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
Hiroyasu Ikegami, MD, PhD; Kiyohisa Ogawa, MD, PhD; Noriaki Nakamichi, MD; Toshiyasu
Nakamura, MD, PhD; Kazuki Sato, MD, PhD; Masato Okazaki, MD; Yoshiaki Toyama, MD,
PhD
3:45pm - 5:00pm
SCIENTIFIC PAPER PRESENTATIONS SESSION B
Moderators: Gregory M. Buncke, MD and David T. W. Chiu, MD
12:45pm – 12:50pm
Treatment of the Divided Spinal Accessory Nerve and Tendon Transfers
Institution where the work was prepared: Boston University School of Medicine, Boston, MA, USA
Harilaos T. Sakellarides, MD
*3:45pm – 3:50pm
In Vivo Electrophysiologic Properties of poly(3,4-ethylenedioxythiophene)
PEDOT in Peripheral Motor Nerves
Institution where the work was prepared: University of Michigan, Ann Arbor, MI, USA
Brent M. Egeland, MD; Melanie G Urbanchek; Sarah M. Richardson-Burns; William M.
Kuzon; Daryl R. Kipke, PhD; David C. Martin; Paul S Cederna
*12:50pm – 12:55pm
Topographic Distribution of Sensory and Motor Axons in the Human
Brachial Plexus: A First Step Toward Function-Specific Targeted
Reinnervation
Institution where the work was prepared: Northwestern University Feinberg School of
Medicine, Chicago, IL, USA
Jason H. Ko, MD; Mauricio De la Garza, MD; Peter S. Kim, MD; Todd A. Kuiken, MD, PhD;
Gregory A. Dumanian, MD
3:50pm – 3:55pm
Intraoperative Nerve Action Potentials Can Determine Optimal
SSEP Stimulus Intensity
Institution where the work was prepared: Sunnybrook Health Sciences Centre, Toronto, Canada
David A. Houlden, PhD; Meghan Cohen; Samantha L. Robertson; Craig P. Stewart; Michael L.
Schwartz; Mahmood Fazl; Farhad Pirouzmand
Panel: Chronic Pain Management
Wyndell Merritt, MD, Moderator
Allan Belzberg, MD
L. Andrew Koman, MD
Lawrence J. Rossi, MD
*3:55pm – 4:00pm
Neuropathy a Late Finding in the Post-Burn Population;
a Four Year Institutional Review
Institution where the work was prepared: Saint Louis University, St. Louis, MO, USA
Johnny Franco, MD; John Scott Ferguson
12:55pm – 1:00pm
Evaluation of Pain Measures Used by Peripheral Nerve Surgeons
Institution where the work was prepared: University of Toronto, Toronto, ON, Canada
Christine B. Novak, PT, MS, PhD(c); Dimitri J. Anastakis; Dorcas E. Beaton; Joel Katz, PhD
38
*4:00pm – 4:05pm
Exogenous Administration of Nerve Growth Factor
(NGF) Establishes a Biphasic Dose-response on Early
Peripheral Nerve Regeneration
Institution where the work was prepared: University of Calgary, Calgary, AB, Canada
Stephen W.P. Kemp, BSc(Hons), MSc; Douglas W. Zochodne; Rajiv Midha
4:05pm – 4:10pm
Discussion
*4:10pm – 4:15pm
Photochemical Sealing of Peripheral Neurorrhaphy, Improving
Electrophysiological and Histological Outcomes
Institution where the work was prepared: Massachusetts General Hospital, Harvard Medical
School, Boston, MA, USA
Francis Patrick Henry, MD; Namita A. Goyal, MD; William S. David, MD, PhD; David Wes,
BA; Mark A. Randolph, MAS; Irene E. Kochevar, PhD; Robert W. Redmond, PhD; Jonathan
M. Winograd, MD
4:15pm – 4:20pm
Lipofibromatous Hamartoma: A Spectrum of Nerve Involvement
Jenny C. Lin, MD, PhD; Suan Cheng Tan, MD; Eric Arruda; Matthew J. Lax, MD; Dimitri J.
Anastakis, MD, MHPE, MHCM
4:20pm – 4:25pm
Brachialis Nerve Transfers for Lower Brachial Plexus Reanimation
Institution where the work was prepared: Renata Weber, Bronx, NY, USA
Renata V. Weber, MD; Thomas HH Tung; Susan E. Mackinnon, MD
*4:25pm – 4:30pm
Transplantation of Olfactory Ensheathing Cells Enhances
Peripheral Nerve Regeneration after Microsugical Nerve Repair
Institution where the work was prepared: Department of Plastic, Hand- and Reconsructive
Surgery, Hannover, Germany
Christine Radtke; Ayal A. Aizer, MD; Karen L. Lankford; Peter M. Vogt; Jeffery D. Kocsis
4:30pm – 4:35pm
Discussion
*4:35pm – 4:40pm
Anatomical Variations of Occipital Nerves: Clinical
Applications for Surgical Treatment of Occipital Neuralgia
Institution where the work was prepared: Georgetown University Hospital, Washington, DC,
USA
Ivica Ducic, MD, PhD; Ali Al-Attar, MD
*4:40pm – 4:45pm
A Quantitative Evaluation of Gross Versus Histologic
Neuroma Formation in a Rabbit Forelimb Amputation Model
Jason H. Ko, MD; Peter S. Kim, MD; Kristina D. O’Shaughnessy, MD; Todd A. Kuiken, MD,
PhD; Gregory A. Dumanian, MD
*4:45pm – 4:50pm
Characterization of a Novel Transgenic Rat Line Over-expressing
Green Fluorescent Protein (GFP)
Institution where the work was prepared: Washington University, St. Louis, MO, USA
Rahul Kasukurthi, BA; Amy Moore; Alice Y. Tong; Nancy Solowski, MD, MS; Janina Luciano;
Ying Yan; Wilson Z. Ray; Susan E. Mackinnon; Gregory Borschel
*4:50pm – 4:55pm
The Role of BFGF and NGF in the Treatment of a Common-Peroneal-Nerve
Gap by Means of Autologous Nerve Grafting In Rats
Institution where the work was prepared: General Hospital “Asclepeion Voulas”, Athens,
Greece
Eleni Ntouvali, MD; Spyridon Deftereos, MD; Theodoros Filippidis, MD; Michalis Sideris;
Grigorios Panagopoulos, MD; Apostolos Papalois, PhD; Panagiotis Athanasiou Kinnas, MD
4:55pm – 5:00pm
Discussion
39
DAY-AT-A-GLANCE
6:00am – 3:00pm
ASPN Poster Viewing
6:00am – 4:00pm
Speaker Ready Room
Silversword
6:30am – 5:00pm
Meeting Services
6:45am – 7:30am
Coffee
IIima
7:00am – 8:00am
IIima 2 & 3
Maile 2 & 3
7:45am – 8:30am
Haleakala Gardens
8:15am – 12:00pm
AAHS/ASPN/ASRM Combined Programming
12:00pm – 12:30pm
ASPN Break with Exhibitors
Haleakala Gardens
12:30pm – 1:00pm
ASPN Business Meeting/Lunch
Haleakala 4 & 5
12:30pm – 1:30pm
ASPN Invited Speaker:
Wyndell H Merritt, MD, FACS
Haleakala 1
1:45pm – 3:00pm
Scientific Paper Session C
Haleakala 4 & 5
6:00pm – 8:00pm
Molokini Gardens
40
Pikake 2 & 3
Plumeria 2 & 3
Hibiscus 1 & 2
Hibiscus 3
ASPN: Saturday January 10, 2009
6:00am – 3:00pm
ASPN Poster Viewing
7:00am – 12:00pm
AAHS/ASPN/ASRM Combined Day Programming
*2:25pm – 2:30pm
RGTA, a Synthetic Glycosaminoglycan Mimetic, Significantly
Reduces Neural Adhesions after Peripheral Nerve Injury in Rats
Institution where the work was prepared: Erasmus MC, Rotterdam, Netherlands
H. Mischa Zuijdendorp; Xander Smit, PhD; B.Stefan de Kool; Joleen H. Blok, PhD; Jean Pierre
Caruelle, PhD; Barritault Denis, PhD; Steven E.R. Hovius, Prof, PhD; J.W. van Neck, PhD
12:00pm – 12:30pm
12:30pm – 1:00pm
ASPN Business Meeting/Lunch
1:00pm – 1:45pm
Invited Speaker
2:30pm – 2:35pm
Discussion
Wyndell H. Merritt, MD, FACS
Where is the Pain? in RSD/CRPS Patients:
The Heart, the Head or the Hand?
2:35pm – 2:40pm
The Medial Intermuscular Septum and the Ulnar Nerve
Institution where the work was prepared: Kleinert Institute for Hand and Microsurgery,
Louisville, KY, USA
Tuna Ozyurekoglu, MD
The conundrum of RSD/CRPS remains unresolved, and brings
into sharp focus our lack of understanding of the complex relationship between the central and peripheral nervous systems. No
comprehensive hypothesis clearly explains the etiology, and no
uniformly successful treatment method exists. All aspects are controversial; including nomenclature, diagnostic criteria, causation,
best treatment, or even if the disorder exists! This presentation
attempts to review some published beliefs, hypothesize an etiological mechanism, and propose rational clinical management
principles (regardless of etiology) along with possible strategies
to reduce development of RSD/CRPS.
Wyndell H. Merritt, MD, FACS currently serves as Clinical
Professor of Plastic Surgery, University of Virginia H.S.,
Charlottesville. Dr. Merritt is also a past president of the
American Society for Peripheral Nerve.
2:40pm – 2:45pm
Brain Derived Neurotrophic Factor (BDNF) Mediates Accelerated
Nerve Regeneration in Response to Brief (1hr) Low Frequency
Electrical Stimulation of the Surgically Repaired Nerve
Institution where the work was prepared: Tessa Gordon, Edmonton, AB, Canada
Tessa Gordon, PhD; Neil Tyreman; L. Pettersson; Valerie Verge, PhD
*2:45pm – 2:50pm
Otfrid Foerster (1873 – 1941) – a Widely Unrecognized Self-Taught
Pioneer of Reconstructive Peripheral Nerve Surgery
Institution where the work was prepared: Hannover Medical School, Hannover, Germany
Andreas Gohritz; A. Lee Dellon, MD; Peter M. Vogt
1:45pm - 3:00pm
SCIENTIFIC PAPER PRESENTATIONS SESSION C
Moderators: David L. Brown, MD, FACS and Martijn J. A. Malessy, PhD
2:50pm – 2:55pm
The Efficacy of NGF Promoting Factor in Nerve Regenaration
Through an Epineural Conduit Flap. Experimental Study in Rabbits
Institution where the work was prepared: Euaggelismos Hospital, Athens, Greece
Antonia Barmpitsioti, MD
1:45pm – 1:50pm
Existence of Neurites Promote Differentiation of Dermal Fibroblasts into
Myofibroblasts and Induce Contraction of Collagen Matrix in Vitro
Institution where the work was prepared: Osaka University Graduate School of Medicine,
Osaka, Japan
Tateki Kubo, MD, PhD; Toshihiro Fujiwara; Kenji Yano; Ko Hosokawa
2:55pm – 3:00pm
Discussion
6:00pm – 8:00pm
*1:50pm – 1:55pm
Contralateral C7 Transfer for Complete Brachial Plexus Avulsion
Institution where the work was prepared: Johns Hopkins, Baltimore, MD, USA
Michael J. Dorsi, MD; Allan J. Belzberg, MD, FRCSC
*1:55pm – 2:00pm
Functional Bio-Artificial Neuro-Muscular Implant for Peripheral Nerve
Interfaces
Mohammad Reza Abidian, MD; Eugene Dariush Daneshvar; Melissa Wright; Brent Egeland,
MD; Melanie Urbanchek; Rachel Miriani; Paul S. Cederna, MD; Daryl R. Kipke, PhD
*2:00pm – 2:05pm
Role Of Microsphere Delivered Nerve Growth Factor (NGF) And Glial Cell
Line Derived Neurotrophic Factor (GDNF) In Peripheral Nerve Regeneration
Ralph De Boer, MD; Andrew M. Knight, PhD; M.J.a. Malessy; Robert J. Spinner; A.J.
Windebank, MD
2:05pm – 2:10pm
Discussion
2:10pm – 2:15pm
Improved Regeneration of Autologous Nerve Transplants by Means of
VEGF-Gene Therapy
Institution where the work was prepared: Department of Plastic Surgery and Hand Surgery,
Munich, Germany
Riccardo E. Giunta; Thomas Holzbach; Rupprecht Milojcic; Thomas Brill; Kaspar Matiasek;
Martina Anton; Bernd Gänsbacher; Hans-Günther Machens
*2:15pm – 2:20pm
Aligned Conducting Polymer Nanotubes for Contact Guidance of Neurite
Outgrowth and Precisely Controlled Release of Neurotrophins in Nerve
Regeneration Applications
Mohammad Reza Abidian, MD; Joseph M. Corey, MD, PhD; David C. Martin, PhD; Daryl R.
Kipke
*2:20pm – 2:25pm
Comparative Gene Expression Profiling Provides Novel Insights in the
Molecular Basis of Misrouting of Axons Through the Neuroma in Continuity
in Obstetrical Brachial Plexus Injuries
Institution where the work was prepared: Netherlands Institute for Neuroscience, Amsterdam,
Netherlands
Martijn R. Tannemaat, MD; Koen Bossers; M.J.a. Malessy; Joost Verhaagen
41
Supported by:
DAY-AT-A-GLANCE
Sunday, January 11, 2009
6:00am – 4:00pm
Speaker Ready Room
Silversword
6:00am – 2:00pm
ASPN Poster Viewing
6:30am – 7:30am
ASPN Coffee with Exhibitors
Haleakala Gardens
6:30am – 2:30pm
Meeting Services
7:00am – 8:00am
ASPN Instructional Courses
301 Surgical Treatment Options for Chronic Headache
302 Neuroma Management
303 CRPS
304 Engineering of Novel Peripheral Nerves
305 Denervation Techniques for Painful
Musculoskeletal Conditions of Neural Origin
306 Nerve Transfer
Pikake 2 & 3
IIima 2 & 3
Maile 2 & 3
Plumeria 2 & 3
Hibiscus 1 & 2
Hibiscus 3
8:15am – 9:15am
ASRM/ASPN Panel: Failed Carpal Tunnel
and Cubital Tunnel Surgery
Haleakala 1
9:15am – 9:45am
Haleakala Gardens
9:45am – 11:00am
Scientific Paper Presentations D
Haleakala 4 & 5
11:00am – 11:45am
ASPN Invited Speaker:
Lawrence J. Rossi, MD, FAAP, DABMA
Haleakala 4 & 5
11:45am – 1:00pm
Scientific Paper Presentations E
Haleakala 4 & 5
1:00pm – 1:15pm
Closing Remarks & Presentation of Awards
Haleakala 4 & 5
1:15pm – 1:45pm
Haleakala 4 & 5
42
ASPN: Sunday, January 11, 2009
6:30am – 7:30am
Coffee with Exhibits
7:00am – 8:00am
Instructional Courses Additional CME 1 Credits each
9:50am – 9:55am
The Clock Face Guide to Peroneal Intraneural Ganglion Cysts:
Critical “Times” and Sites for Accurate Diagnosis
Robert J. Spinner, MD; Gauri Luthra, BA; Nicholas M. Desy, BSc; Meredith L. Anderson, MD;
Kimberly Amrami
Supported by:
9:55am – 10:00am
Toward a Biotic-Abiotic Peripheral Nerve Interface
Melanie G. Urbanchek, MS, PhD; Lisa M. Larkin; Brent M. Egeland, MD; William M. Kuzon Jr,
MD, PhD; David C. Martin; Paul S. Cederna, MD
301 Surgical Treatment Options for Chronic Headache
Course will educate audience about indications for surgical
treatment of chronic headaches, timing of surgery, type and
option of surgeries to be considered and outcomes.
Ivica Ducic, MD
302 Neuroma Management
Trauma, neoplasm, surgical intervention and iatrogenic injury
are some of the reasons for neuroma formation. A portion of
these will become painful and resistant to therapy. We will
explore the current understanding of how neuromas form,
why they can be painful and what the treatment options are.
*10:00am – 10:05am
Cortical Plasticity Following Median Nerve Transection Using 3T fMRI
Seth Jones, MD; Rupeng Li; Christopher Pawela; Younghoon Cho; Ji-Geng Yan; James Hyde;
Hani Matloub
Allan Belzberg, MD
Gene Deune, MD
Michael Dorsi, MD
Stephen Russell, MD
Thomas Tung, MD
10:05am – 10:10am
Discussion
*10:10am – 10:15am
Skin Derived Stem Cells as a Source of Schwann Cells for
Repair of the Chronically Denervated Nerve
Sarah K. Walsh, BSc; T. Gordon; Rajiv Midha
303 CRPS
Wyndell Merritt, MD
304 Engineering of Novel Peripheral Nerves:
Are We Making Any Progress?
Over the past 30 years, there has been a substantial amount
of clinical and basic science research focused on developing
new peripheral nerve conduits utilizing either biologic or synthetic materials. There have been many descriptions of various
nerve substitutes being successfully used for reconstruction of 1-3
cm nerve gaps. However, are we making any substantial
progress towards the development of a tissue engineered
peripheral nerve substitute for reconstruction of long nerve gaps.
Our panel of experts will share with us their clinical and basic
science research efforts and provide their insight into our current
state in peripheral nerve tissue engineering and provide for us
their “best guess” of the future state.
*10:15am – 10:20am
Ischemic Conditions Result in Minimal GFAP Expression in
Satellite Cells of the Dorsal Root Ganglion
Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA
Krzysztof Siemionow, MD; Grzegorz Brzezicki; Aleksandra Klimczak; Maria Siemionow;
Robert McLain
10:20am – 10:25am
Hand Prehension Recovery After Brachial Plexus Avulsion by
Means of Full-length Phrenic Nerve Transfer via Endoscopic
Thoracic Surgery
Institution where the work was prepared: Huashan Hospital, Shanghai, China
Wen-Dong Xu, MD, PhD; Yan-Qun Qiu; Jiu-Zhou Lu; Lei Xu; Jian-Guang Xu; Yu-Dong Gu
Paul Cederna, MD
Gregory Borschel, MD
Rajir Midha, MD
*10:25am – 10:30am
Schwann Cell Migration into Peripheral Nerve Allografts:
A Longitudinal Assessment
Institution where the work was prepared: Washington Unviersity in St Louis School of
Medicine, Saint Louis, MO, USA
Elizabeth L. Whitlock, BA; Terence M. Myckatyn, MD; Alice Y. Tong; Andrew X. Yee, BS; Ying
Yan, MD, PhD; Amy M. Moore; Christina M. Magill, MD; Susan E. Mackinnon, MD
305 Denervation Techniques for Painful
Musculoskeletal Conditions of Neural Origin
Diagnosis and treatment of “musculoskeletal” pain of neural
origin, including partial joint denervation of the shoulder,
elbow, wrist, knee and ankle.
A. Lee Dellon, MD
306 Nerve Transfer
We will discuss the use of intra and extra plexal nerve transfer, distal nerve transfers to restore upper extremity function
after nerve injury.
10:30am – 10:35am
Discussion
Allan T. Bishop, MD
Robert J. Spinner, MD
Thomas Tung, MD
8:15am – 9:15am
*10:35am – 10:40am
Peripherally Versus Centrally Derived Glial Cell Line-Derived
Neurotrophic Factor (GDNF) Provides a Physiologic Stimulus
to Regenerating Motor and Sensory Nerves
Institution where the work was prepared: Washington University School of Medicine, St. Louis,
MO, USA
Christina M. Magill; Amy M. Moore; Ying Yan; Andrew Yee; Alice Y. Tong; Daniel A. Hunter;
Ayato Hiyashi, MD, PhD>; Alexander Parsadanian, PhD; Terence M. Myckatyn, MD
ASRM/ASPN Panel: Failed Carpal
Tunnel and Cubital Tunnel Surgery
Demonstrate surgical and non-surgical methods to treat
patients who continue to have symptoms following carpal
and cubital tunnel release.
Robert Russell, MD, Moderator
Neil F. Jones, MD
Susan Mackinnon, MD
Allen Van Beek, MD
9:15am – 9:45am
10:40am – 10:45am
Patterns of Intraneural Ganglion Cyst Descent
Robert J. Spinner, MD; Stephen W. Carmichael, PhD; Huan Wang, MD, PhD; Thomas J.
Parisi, BA; John A. Skinner; Kimberly Amrami
10:45am – 10:50am
Minimally Invasive Peripheral Nerve Surgery – What is it and Why?
Institution where the work was prepared: Georgetown University Hospital, Washington, DC,
USA
9:45am - 11:00am
SCIENTIFIC PAPER PRESENTATIONS SESSION D
Moderators: Howard M. Clarke, MD and Ranjan Gupta, MD
10:50am – 10:55am
MRI Interpretation Amongst Other Indicators of Malignancy
in Peripheral Nerve Sheath Tumors
Justin M. Brown, MD; Noopur Gangopadhyay, MD; Susan E. Mackinnon, MD
*9:45am – 9:50am
Transplanted Donor Derived Bone Marrow Stromal Cells Engraft
Locally and Systemically when Augmenting the Regeneration
of Peripheral Nerve Defects
William Duggan, MD; Aleksandra Klimczak, PhD; Dileep Nair, MD; James Gatherwright;
Maria Siemionow, MD, PhD, DSc
10:55am – 11:00am
Discussion
43
11:00am – 11:45am
Invited Speaker
*12:25pm – 12:30pm
The Influence of BFGF and/or NGF in the Outcome of End-to-Side
Neurorrhaphy in the Rat-Sciatic-Nerve Experimental Model
Institution where the work was prepared: General Hospital , Athens, Greece
Eleni Ntouvali, MD; Spyridon Deftereos, MD; Theodoros Filippidis, MD; Michalis Sideris;
Grigorios Panagopoulos, MD; Apostolos Papalois, PhD; Panagiotis Athanasiou Kinnas, MD
Acupuncture: History and its use
in Treatment of Pain
This lecture will present a brief overview of the history and
“Westernization” of acupuncture. Basic scientific theory as it
applies to pain management.
Lawrence J. Rossi Jr. M.D., FAAP, DABMA serves as Chief
Department of Anesthesia at Hopedale Medical Complex in
Hopedale, IL. His practice includes Anesthesia and Pain
Management. Dr. Rossi a fellow of the American Academy
of Pediatrics and a diplomat of the American Board of
Medical Acupuncture and diplomat of the American Board
of Anesthesiology.
12:30pm – 12:35pm
Discussion
*12:35pm – 12:40pm
Immunologic Demyelination as a Novel Therapy Following Acute
Injury in the Peripheral Nervous System: A Summary of Our Experience
Institution where the work was prepared: UC Irvine Medical Center, Orange, CA, USA
Aaron M. Kosins, MD, MBA; Thomas Scholz; Gregory RD Evans; Hans S Keirstead
*12:40pm – 12:45pm
Intravenous Copolymer Surfactant P188 Accelerates Post-Axonotemetic
Neuronal Regeneration
Institution where the work was prepared: The Univesity of Chicago, Chicago, IL, USA
Neil D. Dalal, MD; Zhen-du Zhang, MD; Raphael C. Lee, MD, ScD
11:45am - 1:00pm
SCIENTIFIC PAPER PRESENTATIONS SESSION E
Moderators: Michael W. Neumeister, MD and Robert Spinner, MD
12:45pm – 12:50pm
Management of Complicated Brachial Plexus Tumors
Institution where the work was prepared: Washington University in Saint Louis, St. Louis, MO, USA
Jonathan Cheng, MD; Chad A. Perlyn, MD, PhD; Susan E. Mackinnon, MD
*11:45am – 11:50am
Thalamic White Matter Changes are Associated with Chronic Pain Following
Peripheral Nerve Injury and Surgical Repair
Institution where the work was prepared: University Of Toronto, Toronto, ON, Canada
Keri S. Taylor, BSc; Dimitri J. Anastakis, MD, MEd, MHCM; Karen D. Davis, PhD
12:50pm – 12:55pm
Successful Surgical Approach for Treatment of Post-Traumatic
Trigeminal Nerve Pain
Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA
Gedge D. Rosson, MD; Eduardo D. Rodriguez, MD; A. Lee Dellon, MD
*11:50am – 11:55am
Understanding T Helper Phenotype in Peripheral Nerve Allograft Survival
Using STAT Knockout Mice
Wilson Z. Ray, MD; Nancy Solowski, MD, MS; Daniel A. Hunter; Ying Yang; Andrew Yee;
Susan E. Mackinnon; Thomas Tung
12:55pm – 1:00pm
Discussion
11:55am – 12:00pm
Recovery of Rodent Whisking Function Following Crush, Transection, and
Entubulation
Institution where the work was prepared: Massachusetts Eye and Ear Infirmary, Boston, MA,
USA
Tessa A. Hadlock, MD; Jeffrey Kowaleski; David Lo; Susan Mackinnon; James T. Heaton, PhD
12:00pm – 12:05pm
In Vivo Analysis of a Polyethylene Glycol Hydrogel Nerve Glue
Institution where the work was prepared: Virginia Commonwealth University Health System,
Richmond, VA, USA
Jonathan Isaacs, MD; Ivette Klumb, MD; Candice McDaniel, MD
12:05pm – 12:10pm
Discussion
*12:10pm – 12:15pm
Differential Neural Input Influences Muscle Fiber Type of In Vivo Tissue
Engineered Skeletal Muscle
Melissa E. Melvin, MD; Cynthia L. Marcelo; David L. Brown, MD, FACS
*12:15pm – 12:20pm
Poly(3,4-ethylenedioxythiophene) PEDOT Bioengineered Constructs Can
Deliver Afferent SNAPs With High Efficiency
Brent M. Egeland, MD; Melaine G. Urbanchek, PhD; Sarah M. Richardson-Burns, PhD; William
M. Kuzon, MD, PhD; Daryl R. Kipke, PhD; David C. Martin, PhD; Paul S. Cederna, MD
*12:20pm – 12:25pm
The Feasibility of Using Side-to-Side Nerve Grafts to “Protect” Chronically
Denervated Nerve Pathways During Axon Regeneration
Institution where the work was prepared: University of Alberta, Edmonton, AB, Canada
Adil Ladak, MD; P. Schembri, MD; N. Tyreman; J. Olson, MD; Tessa Gordon, PhD
44
1:00pm – 1:15pm
Closing Remarks & Presentation of Awards
1:15pm – 1:45pm
AMERICAN SOCIETY FOR
DAY-AT-A-GLANCE
6:30am – 5:00pm
Meeting Services
6:00am – 4:00pm
Speaker Ready Room
Silversword
6:00am – 4:00pm
ASRM Poster Viewing
Silversword
6:45am – 7:30am
Coffee
IIima
7:00am – 8:00am
IIima 2 & 3
Maile 2 & 3
7:45am – 8:30am
Haleakala Gardens
8:15am – 8:30am
AAHS/ASPN/ASRM Presidents’ Welcome
Haleakala 1
8:30am – 9:30am
PANEL: Crisis in Hand Trauma Coverage
Haleakala 1
9:30am – 10:00am
AAHS/ASPN/ASRM Breakfast with Exhibitors
Haleakala Gardens
10:00am – 11:00am
PANEL: Medical Diplomacy - Volunteering,
Training and the Military
Haleakala 1
11:00am – 12:00pm
Graham Gumley, MD
Haleakala 1
12:00pm
AAHS/ASRM Golf Tournament:
Wailea Country Club
12:00pm – 5:00pm
ASRM Master Series
Haleakala 1
6:00pm – 8:00pm
Molokini Gardens
45
Pikake 2 & 3
Plumeria 2 & 3
Hibiscus 1 & 2
Hibiscus 3
ASRM: Saturday January 10, 2009
6:00am – 4:00pm
Speaker Ready Room
6:45am – 8:15am
Coffee
7:00am – 8:00am
10:00am – 11:00am
AAHS/ASPN/ASRM PANEL: Medical DiplomacyVolunteering, Training, and the Military
Volunteering is a method of medical diplomacy. Many hand
surgeons volunteer their time to care for those in developing
countries. In addition, our military provides humanitarian efforts
across the globe. This panel will highlight those efforts and
emphasize the care, the relationships, and the good will
established during these outreaches.
Miguel Pirela-Cruz, MD, Co-Moderator
Eric Hofmeister, MD, Co-Moderator
Nash Naam, MD
201 Pedicled and Free Flap Reconstruction
for Trauma and Tumors of the Upper Extremity
Amit Gupta, MD
Joseph Upton, MD
202 Current State of the Art Toe Transfers
for Thumb and Finger Reconstruction
11:00am – 12:00pm
Gregory Buncke, MD
Neil F. Jones, MD
Fu Chan Wei, MD
Graham Gumley, MD
203 Introduction to Acupuncture:
Principles and Applications
Helping Our Hands Restore Their Own Feeling
Despite the pace of Globalization this young century, the poor
remain in the dark shadow of health care—not able to see
any advantage from our skills and developments. Sharing our
knowledge and teaching our skills in developing countries
multiplies our work, restores hope where the need is greatest
and returns to us the true satisfaction of our healing profession.
Dr. Gumley will give a talk based on his recent experiences in
the developing world with small teams of Hand and Upper
Limb Surgeons providing free care to the poor, with discussion
about the opportunities, challenges and rewards.
This lecture will introduce the participant to the art and basic science of acupuncture. There will be opportunity to do hands on
needling techniques of some common acupuncture points.
204 Multiple Nerve Transfers for Control
of Upper Extremity Myoelectric Prostheses
(Targeted Reinnervation)
This course will describe sets of nerve transfers to aid high upper
extremity amputees in the intuitive control of their myoelectric prostheses. The surgical procedures, illustrative cases, and outcomes
will be presented.
12:00pm – 5:00pm
Greg Dumanian, MD
Master Series in Microsurgery Additional CME 4 Credits
“Disasters of the Masters”
Lawrence Gottlieb, MD, Chairperson
A nerve gap after injury or tumor is a vexing problem. The gap
can be bridged by graft material or conduit. In addition, the gap
can be bypassed by adjacent nerve transfer. The decision making
process is complicated and this panel will specifically address this
issue. The role of grafting, conduits, and transfers will be discussed
in detail.
James Chang, MD
Susan MacKinnon, MD
Allen Van Beek, MD
This year, the Master Series in Microsurgery will be a little
different from previous years; highlighting complications and
problems. The title of the Master Series in Microsurgery 2009
will be “Disasters of the Masters”. An international panel of
renowned Masters of Microsurgery will present disasters that
they have created, show us how they dealt with disasters they
inherited and teach us how to avoid disasters.
Pre registration is required
12:00pm – 12:30pm
206 Brachial Plexus Surgery-What Works and
What Does Not Work
12:30pm – 12:45pm
Brachial plexus reconstruction is a demanding procedure with the
goal of maximizing arm function after regeneration. However, the
number of viable axons may be limited and priority must be given
downstream to achieve optimum outcome. In addition, nerve transfers from within the plexus and outside the plexus can increase available axons. This course will critically evaluate the role of neurolysis,
nerve grafting, and nerve transfers in brachial plexus reconstruction.
Allen Bishop, MD
Robert Spinner, MD
8:15am – 8:30am
Lunch in Meeting Room
Master Series Attendees Only
Welcome Introduction
12:45 – 1:10pm
Chest Wall/Trunk
1:10pm – 1:35pm
Breast
Guenter Germann, MD
Stefan Hofer, MD
1:35pm – 2:00pm
Lower Extremity
AAHS/ASPN/ASRM President’s Welcome
2:00pm – 2:25pm
Maxillofacial Trauma
Eduardo Rodriguez, MD
Scott H. Kozin, MD, AAHS President
2:25pm – 2:40pm
Discussion/Questions
2:40pm – 2:55pm
Break
2:55pm – 3:20pm
Facial Paralysis
Eyal Gur, MD
3:20pm – 3:45pm
Head & Neck
Peter Neligan, MD
3:45pm – 4:10pm
Nasal Reconstruction
Robert Walton, MD
4:10pm – 4:35pm
4:35pm – 4:50pm
8:30am – 9:30am
9:30am – 10:00am
Toe-To-Hand Transfers
Fu-Chan Wei, MD
AAHS/ASPN/ASRM PANEL:
Crisis In Hand Trauma Coverage
Neil F. Jones, MD
E. Anne Ouellette, MD
Luis Scheker, MD
4:50pm – 5:00pm
Discussion/Questions
Closing Remarks
6:00pm – 8:00pm
46
Supported by:
DAY-AT-A-GLANCE
Sunday, January 11, 2009
6:30am – 7:30am
Haleakala Gardens
6:30am – 2:30pm
Speaker Ready Room
Silversword
6:30am – 2:30pm
Meeting Services
6:30am – 2:30pm
ASRM Poster Viewing
Silversword
7:00am – 7:15am
Welcome:
Neil F. Jones, MD, President
J. Brian Boyd, MD, Program Chair
Haleakala 1
7:15am – 8:15am
Concurrent Paper Presentations Sessions
Research I
Clinical: Nerve and Non-Microvascular
Haleakala 2 & 3
Haleakala 1
ASPN/ASRM Panel:
Failed Carpal Tunnel & Cubital Tunnel Surgery
Haleakala 1
9:15am – 9:45am
Haleakala Gardens
9:45am – 10:45am
PANEL: Lower Extremity Update: State of the Art
Haleakala 1
10:45am – 11:45am
President’s Invited Lecturer:
Thomas E. Starzl, MD
Haleakala 1
11:45am – 12:15pm
Lunch with Exhibitors
Haleakala Gardens
12:15pm – 1:30pm
ASRM Mini Panels
1S Breast Reconstruction: A Woman’s Perspective
2S Perforator Flaps: Ebb and Flow?
3S Alternative to CTA in Facial Reconstruction
4S Surgical Options in the Diabetic Extremity
5S Vessel Imaging in Autogenous Breast Reconstruction
6S Plan B in Microsurgery
Pikake 2 & 3
IIima 2 & 3
Hibiscus 3
Plumeria 2 & 3
Hibiscus 1 & 2
Maile 2 & 3
Godina Lecture: Michael Sauerbier, MD
Haleakala 1
8:15am – 9:15am
1:30pm – 2:30pm
47
ASRM: Sunday, January 11, 2009
6:30am – 7:30am
Coffee
7:00am – 7:15am
Welcome
8:00am – 8:05am
Composite Tissue Transplantation: Are Concerns about Over
Immunosuppression Unwarranted?
Institution where the work was prepared: University of Louisville, Jewish Hospital Transplant
Center, Louisville, KY, USA
Jf Buell, MD; Kv Ravindra, MD; M. Marvin; R. Nagubandi; B. Blair; Cl Kaufman, PhD; Wc
Breidenbach, M
8:05am – 8:10am
End-to-side versus End-to-end Ulnar nerve Transfer in Upper Trunk Brachial
Plexus Lesions
Institution where the work was prepared: PUCRS University, Porto Alegre, Brazil
Marcos Jaeger, MD, PhD; Jefferson Braga-Silva; Javier Roman, MD; Mónica Rodrigues, MD
*8:10am – 8:15am
Refinements in Targeted Reinnervation in Transhumeral Amputees:
Proximal Radial Nerve Anatomy and Advancements in Operative
Technique
Jason H. Ko, MD; Peter S. Kim, MD; Kristina D. O’Shaughnessy, MD; Christopher J. Wilson,
MD; Todd A. Kuiken, MD, PhD; Gregory A. Dumanian, MD
J. Brian Boyd, MD, ASRM
Program Chairperson
7:15am - 8:15am
ASRM SCIENTIFIC PAPER PRESENTATION:
Clinical: Nerve and Non-Microvascular
Moderator: William A. Zamboni, MD
(Times include discussion period)
7:15am - 8:15am
ASRM CONCURRENT SCIENTIFIC PAPER PRESENTATION:
Research I
Moderator: Guenter Germann, MD
7:15am – 7:20am
Smile Reconstruction Using a Combined Technique of Temporalis
Muscle Transfer and Selective Botulin Toxin in the Treatment of
the Long Lasting Unilateral Facial Paralysis
Institution where the work was prepared: PUCRS UNIVERSITY, PORTO ALEGRE, Brazil
Marcos Jaeger, MD, PhD; David Sena, MD; Tomas Bergonsi, MD; Janine Mensch, PT; Pedro
Escobar Martins, MD; Jefferson Braga- Silva, MD, PhD, LD
7:15am – 7:20am
Tolerance to a Composite Tissue Allografts after the Induction
of Mixed Chimerism In a Pre-Clinical Large Animal Model
Institution where the work was prepared: University of Washington, Seattle, WA, USA
David W. Mathes; James Edwards; Jeff Scott; Tiffany Miwongtum; Scott Graves, PhD; Rainer Storb
*7:20am – 7:25am
Reconstruction of Mandible Defects Using Human Recombinant BMP-2
Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh,
PA, USA
Alex K. Wong, MD; Galen S. Wachtman, MD; Ernest K. Manders, MD
7:20am – 7:25am
Sacrificial Microfiber Networks: Towards the Fabrication of
Vascularized Tissue Constructs
Institution where the work was prepared: Weill Cornell Medical College, New York, NY, USA
Leon M. Bellan, BS, MS; Harold G. Craighead, PhD; Sunil P. Singh, BA; Jason A. Spector, MD
*7:25am – 7:30am
Reconstruction of Pelvic Exenteration Defects with the
Anterolateral Thigh-Vastus Lateralis Muscle Flaps
Institution where the work was prepared: University of Texas, M.D. Anderson Cancer Center,
Houston, TX, USA
Sarah Hew-Ming Wong, MD; Peirong Yu
*7:25am – 7:30am
In Vivo Tissue Construct and Growth Chamber Interface: Surface
Modification to Optimize Tissue Engineered Construct Yield
Ian F. Lytle, MD; Deborah Buffington; H. David Humes, MD; David L. Brown, MD
*7:30am – 7:35am
The Pedicled Peroneal Artery Perforator Flap for Soft Tissue
Coverage of the Leg and Foot Defects
Institution where the work was prepared: Chang Gung Memorial Hospital, LinKou, Taiwan
Ting-Chen Lu, MD; Cheng-Hung Lin, MD; Ruei-Feng Chen, MD; Yu-Te Lin; Chih-Hung Lin
7:30am – 7:35am
A Novel Sutureless Technique for Microvascular Anastomosis
Using Thermoreversible Poloxamers
Institution where the work was prepared: Stanford University, Stanford, CA, USA
Edward I. Chang, MD; Cynthia D Hamou; Michael G Galvez; Samyra El-ftesi; Jayakumar
Rajadas; Michael T Longaker; Geoffrey C Gurtner
7:35am – 7:40am
The Pedicle Descending Branch Muscle-sparing Latissimus
Dorsi Flap for Breast Reconstruction
Institution where the work was prepared: UT Southwestern Medical Center at Dallas, Dallas,
TX, USA
Michel Saint-Cyr, MD; Purushottam Nagarkar; Mark Schaverien; Phillip Dauwe; Corrine
Wong; Rod J. Rohrich
7:35am – 7:40am
Mesenchymal Stem Cells Prolongation of Composite Tissue
Allotransplantation Survival in a Swine Model
Institution where the work was prepared: Yur-Ren Kuo, Kaohsiung, Taiwan
Yur-Ren Kuo, MD, PhD, FACS; Hsiang-Shun Shih, MD; Shigeru Goto, MD, PhD; Feng-Sheng
Wang; Fu-Chan Wei, MD, FACS; W.P. Andrew Lee
*7:40am – 7:45am
Use of Pedicled Subpectoral Fascia Flap for Expander Coverage
in Post-Mastectomy Breast Reconstruction – A Novel Technique
Institution where the work was prepared: UT Southwestern Medical Center at Dallas, Dallas,
TX, USA
Hema Thakar, MD; Michel Saint-Cyr; Purushottam Nagarkar; Phillip Dauwe; Corrine Wong;
Rod J. Rohrich
*7:40am – 7:45am
Novel Approach to Tissue Engineering and Gene Therapy
Using Bioreactor Manipulated Explanted Microvascular Beds
Institution where the work was prepared: Stanford University School of Medicine, Stanford,
CA, USA
Edward I. Chang, MD; Samyra El-ftesi; Ivan N Vial; Denise A Chan; Geoffrey C Gurtner
*7:45am – 7:50am
Single-Stage Reconstruction of Massive Damage Control
Abdomen Using a Vicryl Mesh Buttress
Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA
Theresa Y. Wang, MD; River Elliott, MD; Benjamin Chang, MD
*7:45am – 7:50am
Effects of High Dose Radiation on Hypoxia-Induced Neovascularization
Institution where the work was prepared: New York University Langone Medical Center, New
York, NY, USA
Phuong D. Nguyen, MD; Oren Z. Lerman, MD; Robert J. Allen Jr, MD; Vishal Thanik;
Christopher C. Chang; Stephen M. Warren; Pierre B. Saadeh; Jamie P. Levine
7:50am – 7:55am
Versatility of Perforator Propeller Flaps: A Creative
Approach for Reconstruction
Institution where the work was prepared: Universite de Montreal, Montreal, Canada
Catherine Lecours, MD; A. Gagnon; C. Bernier; Emile Mailhot; Jenny C. Lin; M. Tardif; A.
Chollet
*7:50am – 7:55am
Fully MHC-Mismatched Face Transplantation: Comparison of
the Tolerogenic Effects of Different Cell–Based Supportive Therapies
Mikael Hivelin, MD; Erhan Sonmez; Aleksandra Klimczak; Serdar Nasir; James Gatherwright;
Maria Siemionow
7:55am – 8:00am
Refining Donor Criteria for Hand Transplantation
Institution where the work was prepared: Christine M. Kleinert Institute, Louisville, KY, USA
Kv Ravindra, MD; C. Kaufman, PhD; Wc Breidenbach
48
(3S)
*7:55am – 8:00am
Pulsed Acoustic Cellular Therapy as a Protective Technology Against
Ischemia/Reperfusion Injury in Skeletal Muscle. A Preliminary Report
Joanna Cwykiel, M, Sc; Lukasz Krokowicz; Aleksandra Klimczak; Maria Siemionow
8:00am – 8:05am
Detection and Classification of Perfusion Differences in a Partial
Venous Obstruction Model Using Near-Infrared Oximetry
Institution where the work was prepared: University of Wisconsin, Madison, WI, USA
John Russell, MS; Mark Kiehn; Nadine Connor; Alejandro Munoz; Gregory Hartig
Julian Pribaz, MD, Moderator
Jacques Baudet, MD
Robert Walton, MD
8:05am – 8:10am
Expanding the Limits of Macroreplantation; 18 Hours Forelimb
Survival of Amputated Extremities Using Extracorporeal Perfusion
With the Heart-Lung Machine in a Porcine Model
Institution where the work was prepared: Department of Orthopaedic, Plastic and Hand
Surgery, University of Bern, Switzerland
Esther Vögelin, MD, PhD; Mihai Constantinescu, MD
8:15am – 9:15am
(4S)
(5S)
9:45am – 10:45am
ASRM Panel: Lower Extremity Update:
State of the Art
Vessel Imaging in Autogenous
Breast Reconstruction
Risal Djohan, MD, Moderator
Robert Allen, MD
Moustapha Hamdi, MD, PhD
Masia Jaume, MD
Michael Samson, MD
Robert Russell, MD, Moderator
Neil F. Jones, MD
Susan Mackinnon, MD
Allen Van Beek, MD
Surgical Options in the Diabetic Extremity
This presentation will emphasize the problem of developing
superimposed comprehensive neuropathy in the diabetic
patient population. It will outline pathologic mechanisms of
development of superimposed compressive neuropathy in
diabetics and will present conservative surgical treatment
options for patients with diabetic neuropathy.
A. Lee Dellon, MD, Moderator
Chris Attinger, MD
Maria Siemionow, MD
ASPN/ASRM Panel: Failed Carpal Tunnel
and Cubital Tunnel Surgery
Demonstrate surgical and non-surgical methods to treat
patients who continue to have symptoms following carpal
and cubital tunnel release.
9:15am – 9:45am
Alternatives to CTA in Facial Reconstruction
To review the different modalities and technology available for autogenous breast reconstruction. The panelists
will discuss the methods used for pre-operative planning in
imaging the anatomy of the perforators to be used for the
flap. The presentation by other panelists will further
expand to other modalities that would confirm the tissue
perfusion of the flap based on the planned imaging.
(6S)
Plan B in Microsurgery
Peter Neligan, MD, Moderator
Guenter Germann, MD
Robert Russell, MD
Randy Sherman, MD
Emmanuel Melissinos, MD
Minoru Shibata, MD
1:30pm – 2:30pm
Godina Lecture
10:45am – 11:45am President’s Invited Lecture
Thomas Starzl, MD
“Marko Godina was distinguished by his tireless energy,
his impeccable logic, his boundless optimism, and his constant good humor and courtesy” – G. Lister
Dr. Thomas E. Starzl is known as the father of transplantation and performed the world’s first successful liver transplant. He has pioneered a new field of medicine that has
become an accepted medical practice. Dr. Starzl earned
his bachelor’s degree in biology and then proceeded on
to Northwestern University Medical School to study anatomy, neurophysiology and obtain his medical degree with
distinction. Dr. Starzl has had the honor of being a Markle
Scholar in Medical Science and the recipient of the National
Medal of Science, the nation’s highest scientific honor. Over
his career Dr. Starzl has done ground breaking work in
transplantation medicine and transformed the face of science
and medicine.
It is these qualities that are sought after in choosing the ASRM
Godina Lecturer, honoring Dr. Marko Godina, an unrivaled
leader and innovator in reconstructive microsurgery whose
life was tragically cut short at the young age of 43. Established
by the trustees of the Marko Godina Fund, this distinguished
lectureship highlights a young, upcoming microsurgeon who
has demonstrated leadership, innovation and ongoing commitment to our field in the best traditions of Dr. Godina. It is a
pleasure to introduce Michael Sauerbier, MD as the 2008
Godina Traveling Fellow.
11:45am –12:15pm Lunch with Exhibitors
12:15pm – 1:30pm
(1S)
Teachers and Mentors in Reconstructive
Microsurgery – the Way it Can Influence
a Professional Career
Mini Panels - Additional CME 1 hour each
In order to conserve time, the Instructional Course format
has slightly changed. This year simultaneous ‘Mini- Panels
lasting 75min each will consist of 3-5 participants.
Becoming a good doctor and an experienced
Reconstructive Microsurgeon can be a long and winding
road with a lot of success but also disappointing moments.
Teachers and mentors who also had to go through such
moments are very important to develop an own profile of
how to act in important or difficult situations. This leads to
the point of willing to teach and share what I have learned
from important people in my life.
Breast Reconstruction: A Woman’s Perspective
Women are entering the field of microsurgery in unprecedented numbers, and they often incorporate breast reconstruction as a significant portion of their practice. It is possible that a woman’s perspective may influence the viewpoint and approach to a woman’s concerns during reconstructive surgery. This Mini Panel will include the following
topics: Determination of the type of reconstruction – finding
the best fit for a woman’s body, lifestyle, and aesthetic
goals, optimization of the donor site in microsurgical
breast reconstruction, achieving symmetry sooner, balancing a microsurgery practice with lifestyle.
Michael Sauerbier, MD, PhD is currently Chairman and
Professor at the Department for Plastic, Hand and
Reconstructive Microsurgery at the Main-Taunus-Hospitals in
Hofheim and Bad Soden am Taunus, Academic Hospital of
the University of Frankfurt, Germany. He is also affiliated as
Associate Professor at the University of Heidelberg,
Germany. Dr. Sauerbier received a degree in medicine from
the University of Wuerzburg, Germany where he also performed his doctoral thesis. He did a research fellowship at
the Mayo Clinic in Rochester, MN, USA and worked on his
PhD thesis in the biomechanical field of the forearm and
hand. Dr. Sauerbier was Vice Chair at the Department of
Hand, Plastic and Reconstructive Surgery at the BG-Trauma
Center in Ludwigshafen / University of Heidelberg, Germany
until 2007. His main interest in Reconstructive Microsurgery is
limb reconstruction, especially after sarcoma resection and
after trauma as well as thoracic wall reconstruction.
Joan Lipa, MD, Moderator
Karen Horton, MD, MSc, FRCSC
Andrea Pusic, MD
Aldona Spiegel, MD
(2S)
Perforator Flaps: Ebb or Flow?
Perforator Flaps - Fad or fiction? What is their long term role?
Geoff Hallock, MD, Moderator
Ming Huei Cheng, MD
Isao Koshima, MD
Steve Morris, MD
49
DAY-AT-A-GLANCE
Monday, January 12, 2009
6:30am – 2:30pm
Speaker Ready Room
Silversword
6:30am – 2:30pm
ASRM Poster Viewing
Silversword
6:30am – 4:00pm
Meeting Services
6:30am – 8:00am
Breakfast
Haleakala Gardens
7:00am – 8:00am
Concurrent Scientific Paper Sessions
Clinical: Extremities I
Outcome Studies
Haleakala 1
Haleakala 2 & 3
7:00am – 8:00am
ASRM Past President’s Breakfast (invite only)
Maile 1
8:00am – 9:00am
Buncke Lecture: Ralph Manktelow, MD
Haleakala 1
9:00am – 10:00am
PANEL: Head and Neck Microsurgery:
State of the Art
Haleakala 1
Concurrent Scientific Paper Presentations
Clinical: Head and Neck I
Research II
Haleakala 1
Haleakala 2 & 3
11:00am – 11:30am
Presidential Address: Neil F. Jones, MD
Haleakala 1
11:30am – 1:30pm
Best Case/Best Save Presentations & Luncheon
Haleakala 1
1:30pm – 2:30pm
Concurrent Scientific Paper Presentations
Clinical: Extremities II
Head and Neck II
Haleakala 2 & 3
Haleakala 1
Mini Panels
1M Brachial Plexus Challenges & Solutions
2M Nerve and Muscle Transfers
4M Sarcoma Reconstruction
Plumeria 2 & 3
Maile 2 & 3
Hali 2 & 3
ASRM 25th “Silver” Anniversary Celebration Gala
Chapel Lawn
10:00am – 11:00am
2:30pm – 3:45pm
6:30pm – 10:00pm
50
7:00am - 8:00am - ASRM PAPER SESSION CLINICAL:
Outcome Studies
Moderator: Achilles Thoma, MD
ASRM: Monday, January 12, 2009
7:00am - 8:00am - ASRM PAPER SESSION CLINICAL:
Extremities I
Moderator: Randy Sherman, MD
*7:00am – 7:05am
Free Flap Breast Reconstruction in Advanced Age: Is it Safe?
Institution where the work was prepared: Division of Plastic Surgery, University of
Pennsylvania, Philadelphia, PA, USA
Jesse Creed Selber, MD, MPH; Meredith Bergey; Seema Sonnad; Joseph Serletti
*7:00am – 7:05am
Functional Assessment of Microsurgical Heel Reconstruction
Due to Landmine Explosions
Institution where the work was prepared: Gulhane Military Medical Academy, Ankara, Turkey
Fatih Zor; Levent Tekin; Ismail Safaz; Serdar Ozturk; Mustafa Deveci; Selcuk Isik
7:05am – 7:10am
Patient Satisfaction with Breast Reconstruction Following Nipple Sparing
Mastectomy
Steven Bernard, MD; Robert Lohman, MD; Risal Djohan, MD
*7:05am – 7:10am
Lower Extremity Arterial Injury Patterns in Patients Requiring
Free Flap Reconstruction: a Fifteen Year Review
Institution where the work was prepared: New York University Langone Medical Center, New York,
NY, USA
Nicholas Haddock, MD; Katie Weichman, MD; Evan Garfein, MD; Daniel J. Ceradini, MD;
Jamie Levine, MD; Pierre B. Saadeh
7:10am – 7:15am
The Effect of Using Skin Flaps and Skin Grafts for Scrotal Reconstruction on
Testicular Function
Institution where the work was prepared: Afyon Kocatepe University, Afyon, Turkey
Yavuz Demir, MD; Fatma Aktepe; Nazli Sancaktar; Sebahattin Kandal; Nurten Turhan
Haktanir
*7:10am – 7:15am
Quantifying the Advantage of Vascular Studies in the Pre-operative
Evaluation of Recipient Vessels in Lower Extremity Reconstruction
Institution where the work was prepared: University of Montreal, Montreal, QC, Canada
Photis Loizides, MD; David Mok; V. St-Supéry, MD; Patrick Harris; Andreas Nikolis; C. Guertin
7:15am – 7:20am
Telemedicine in Microsurgery: Case Study and Critical Evaluation
Institution where the work was prepared: Buncke Clinic, San Francisco, CA, USA
Matthew J. Trovato, MD; Mark S. Granick, MD; Rudolf F. Buntic; Gregory M. Buncke
*7:15am – 7:20am
Distal Lower Extremity Reconstruction with 180-degree Perforator-Based
Propeller Flaps: Microsurgery without the Anastomosis
Institution where the work was prepared: The Johns Hopkins University School of Medicine,
Baltimore, MD, USA
Ariel N. Rad, MD, PhD; Michael R. Christy, MD; Eduardo D. Rodriguez; Julie E. Park, MD;
Jonas A. Nelson; Anshuman Bansal; Gedge D. Rosson, MD
*7:20am – 7:25 am
Pulmonary Complications and Upper Respiratory Tract Bacterial Flora
Alteration Following Free Ileocolon Transfer for Esophageal and Voice
Reconstruction
Institution where the work was prepared: E-Da Hospital / I-Shou University, Kaohsiung County,
Taiwan
Antonio Rampazzo; Bahar Bassiri Gharb; Christopher J. Salgado, MD; Samir Mardini, MD;
Stefano Spanio di Spilimbergo; Hung-Chi Chen, MD, FACS
*7:20am – 7:25am
IVaS Technique for Various Type of Lymphatico-Veous Anastomosis(LVA)
Institution where the work was prepared: Tokyo university department of plastic & reconstructive surgery, tokyo bunkyo-ku hongo 7-3-1, Japan
Mitsunaga Narushima; Isao Koshima; Makoto Mihara; Jun Araki; Yusuke Yamamoto
*7:25am – 7:30am
Augmentation of Surgical Angiogenesis in Vascularized Bone
Allotransplants with Host-Derived AV Bundle Implantation, Fibroblast
Growth Factor-2 and Vascular Endothelial Growth Factor Administration
Mikko Larsen, MD; Wouter F. Willems; Patricia F. Friedrich; Allen T. Bishop
7:25am – 7:30am
Microsurgical Soft Tissue Reconstruction With Temporary
Arterio-Venous Loops and Free Tissue Transfer
Marcus Spies; Christian B. Herold, MD; Gerrit Wunsche, BS; Karsten Knobloch, MD, PhD;
Peter M. Vogt
7:30am – 7:35am
The Influence of Infonomic and Sociodemographic Factors on Shared
Decision Making in Microsurgical Breast Reconstruction
Institution where the work was prepared: Beth Israel Deconess Medical Center, Harvard medical School, Boston, MA, USA
Janet H. Yueh, BA; Evan Matros, MD; Eran D. Bar-Meir, MD; Theodore T. Nyame, BA; Adam
M. Tobias, MD; Bernard T. Lee, MD
7:30am – 7:35am
Second Toe Extensor Digitorum Brevis Provides a Simultaneous
Abductorplasty to Free Vascularized Metatarsophalangeal
Joint Transfer for Thumb Composite Metacarpophalangeal Joint Defect
Institution where the work was prepared: Chang Gung Memorial Hospital, Taoyuan county, Taiwan
Chih-Hung Lin, MD
7:35am – 7:40am
Is Microsurgical Hepatic Artery Repair Worthwhile in Pediatric Liver
Transplantation?
Institution where the work was prepared: The Hospital for Sick Children, Toronto, Canada
Andre Panossian, MD; Ronald M. Zuker, MD, FRCS(C), FAC; Ivan Diamond, MD; a. Fecteau,
MD; D. Grant, MD
7:35am – 7:40am
Subtotal Thigh Flap and Bioprosthetic Mesh Reconstruction
of Large, Composite Abdominal Wall Defects
Institution where the work was prepared: M.D. Anderson Cancer Center, Houston, TX, USA
Samuel Lin; Lawrence Gottlieb; Charles Butler
*7:40am – 7:45am
Outcomes of Soft Tissue Reconstruction after Sarcoma Tumor Resection in
Children
Institution where the work was prepared: The Hospital fo Sick Children, Toronto, Canada
T.K.S. Cypel, MD; B. Meilik; W. Cole; A. Weiss-Meilik; R.M. Zuker
*7:40am – 7:45am
Preoperative Vascular Evaluation Using Computed Tomographic
Angiography (CTA) for Reconstruction of Lower Extremity
Traumatic Defects with Free Tissue Transfer
Ahmet Duymaz, MD; Furkan Karabekmez; Samir Mardini; Steven L. Moran
*7:45am – 7:50am
Chimerism, Malignancy, and Prolonged Graft Survival of Composite Facial
Allografts in Non-Human Primates
Institution where the work was prepared: University of Maryland School of Medicine,
Baltimore, MD, USA
Arthur J. Nam, MD; Matthew G. Stanwix, MD; Eduardo D. Rodriguez, MD, DDS; Steven
Shipley, DVM; Stephen T. Bartlett, MD; Rolf N. Barth, MD
7:45am – 7:50am
Expanded Perforator Free Flap Transfer
Institution where the work was prepared: University of Sao Paulo, Sao Paulo, Brazil
Fabio Busnardo, MD; Marcelo Olivan; Jose Carlos Faria; Marcus Castro Ferreira, MD, PhD
7:50am – 7:55am
Methods of Free Flap Monitoring in a Non-Specialized Unit
Robert Lohman; Risal Djohan; Claude-Jean Langevin; Steven Bernard; Daniel Alam; Maria
Siemionow
7:50am – 7:55am
Limb Salvage in Patients With Advanced Peripheral Vascular
Disease and Complex Foot and Ankle Wounds: Free Flap vs. Amputation
Institution where the work was prepared: Georgetown University Hospital, Washington, DC, USA
Ivica Ducic, MD, PhD; Christopher Attinger; Nathan Menon
*7:55am – 8:00am
Disparate Outcomes for African American Women Following Autologous
Breast Reconstruction: Seven Year Evaluation of 17,436 Patients from the
Nationwide Inpatient Sample
Institution where the work was prepared: Johns Hopkins University School of Medicine,
Baltimore, MD, USA
Brendan J. Collins, MD; David C. Chang, PhD; Gedge D. Rosson, MD
7:55am – 8:00am
Expanding the Limits of Macroreplantation: 18 hours Forearm Survival of
Amputated Extremities using Extracorporeal Perfusion with the Hear-Lung
Machine in a Porcine Model
Institution where the work was prepared: Dr. Esther Vogelin, Bern, Germany
Esther Vogelin, MD, PhD
51
8:00am – 9:00am
Buncke Lecture
*10:35am – 10:40am
Free Partial Superior Latissimus (PSL) Muscle Flap in Head and
Neck Reconstruction
Sendia Kim, MD; Darrell Brooks, MD; Rudy F. Buntic, MD
Supported by:
Ralph Manktelow, MD
The Harry Buncke Lectureship has been created with the
support of the California Pacific Medical Center to honor
Dr. Buncke’s remarkable contributions to the field of microsurgery. Dr. Harry Buncke has played a major role in the
development of our specialty and has helped develop
several microsurgical laboratories across the globe. He
has influenced countless residents and fellows as well as
numerous department chairs throughout the world. It is
with great appreciation that we are able to honor Dr.
Harry Buncke with his lectureship due to the sponsorship
of the California Pacific Medical Center. It is our pleasure
to introduce Ralph Manktelow, MD as the 2009 Harry
Buncke Lecturer.
10:40am – 10:45am
Fingertip Replantations
Takaaki Hasuo; Genzaburo Nishi
10:45am – 10:50am
Face Transplant for Plexiform Neurofibroma 18 Months Follow Up
Institution where the work was prepared: CHU Henri Mondor Paris XII University, CRETEIL,
France
Laurent A. Lantieri, MD; Philippe Grimbert; Jean Paul Meningaud; Franck Bellivier; Nicolas
Ortonne; Marc David Benjoar; Pierre Wolkenstein
Creating Change and Responding to it
As a surgeon we are often active agents of change. We
modify and create new operations. We make some
operations popular and we retire others.
Thirty years ago microsurgery did not even exist. Now it
is an established surgical technique which is huge and
world wide in practice. As surgeons we love to change
surgical practices.
However our approach to changes that we do not initiate
is quite different. Frequently we have difficulty absorbing
changes which appear to be foisted upon us - For example there are changes in our natural environment - such
as climate change, changes in our political environment such as the rise in power of other countries, changes in
our medical economic environment - such as the rise of
health service providers and changes in our medical
practice environment - such as changes in hospital privileges affecting our ability to do surgery. How we deal
with these changes is critical to our survival as persons
and to the survival of our surgery.
Dr. Manktelow will present his thoughts on creating change
and responding to it.
9:00am – 10:00am
10:50am – 10:55am
Microsurgical Salvage of the Intractable Oral Vestibule
Institution where the work was prepared: Division of Plastic, Reconstructive & Maxillofacial
Surgery, R A, Baltimore, MD, USA
Suhail Mithani, MD; Hugo St-Hilaire, MD, DDS; Eduardo Rodriguez, MD, DDS
10:55am – 11:00am
Total Maxillary and Inferior Orbit Reconstruction With Fibula
Osteocutaneous Flaps
Michael Fritz, MD; Steven Cannady, md; Joseph Scharpf, MD; Robert Lorenz, MD
10:00am -11:00am
Panel: Head and Neck Microsurgery:
State of the Art
This panel will highlight esophagus and voice reconstruction.
*10:00am – 10:05am
Retrograde Internal Mammary Venous Anastomosis To Augment Outflow
In DIEP Flap Breast Reconstruction
Institution where the work was prepared: University of Utah, Salt Lake City, UT, USA
Mahlon Alder Kerr-Valentic, MD; Jayant P. Agarwal, MD
Peter Neligan, MD, Moderator
Hung Chi Chen, MD
Joseph Disa, MD
Peirong Yu, MD
10:00am - 11:00am
ASRM PAPER SESSION CLINICAL:
Research I I
Moderator: Gregory R. D. Evans, MD, PhD
Head and Neck I
Moderator: Stefan O. P. Hofer, MD
*10:05am – 10:10am
VEGF Upregulates iNOS Expression in the Muscle Flap Ischemia Model in
the Rat
Institution where the work was prepared: University of Mississippi Medical Center, Jackson,
MS, USA
Barbara Persons, MD; Zeng-Gan Chen, MD; Lin Lin; William Lineaweaver, MD; Feng Zhang,
MD, PhD
10:00am – 10:05am
Two Small Independent Flaps from One Radial Forearm Donor Site for
Buccal Mucosa Reconstruction after Release of Submucous Fibrosis
Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, Taiwan
Chung-Kan Tsao; Fu-Chan Wei, MD, FACSn/a; Ming-Huei Cheng, MD, proffesor; ChweiChin Chuang, MD, proffesor; Jeng-Yee Lin, MD
*10:10am – 10:15am
Activated Protein C Improves Ischemic Flap Survival Via Angiogenic and
Anti-Inflammatory Gene Modulation
Institution where the work was prepared: Dalhousie University, Halifax, NS, Canada
Michael Bezuhly, MD; Steven F. Morris, MD, MSc; Ridas Juskevicius, MD; R. William Currie,
PhD; Kenneth A. West, MD; Robert S. Liwski, MD, PhD
*10:05am – 10:10am
Monitoring Buried Fasciocutaneous Free Flaps in
Pharyngoesophageal Reconstruction
Institution where the work was prepared: University of Texas MD Anderson Cancer Center,
Houston, TX, USA; Robert EH Ferguson, MD; Peirong Yu, MD
10:10am – 10:15am
Microvascular Free Tissue Transfer of Previously Irradiated Flaps
Samuel Lin, MD; Matthew M. Hanasono, MD
*10:15am – 10:20am
The Impact of Various Components of Facial Allograft on Chimerism
Induction in Different Face Transplant Models
Aleksandra Klimczak, PhD; Galip Agaoglu; Ilker Yazici; Sakir Unal; Yalcin Kulahci; Maria
Siemionow
*10:15am – 10:20am
Motility Differences in Free Colon and Free Jejunum Flaps for
Reconstruction of the Cervical Esophagus
Institution where the work was prepared: E-Da Hospital / I-Shou University , Kaohsiung
County, Taiwan
Antonio Rampazzo, MD; Hung-Chi Chen, MD, FACS; Bahar Bassiri Gharb; Marcus TC
Wong; Samir Mardini, MD; Christopher J. Salgado, MD
*10:20am – 10:25am
Alternative Vascular Pedicle of the Anterolateral Thigh Flap: The Oblique
Branch of the Lateral Circumflex Femoral Artery
Institution where the work was prepared: Department of Plastic Surgery, Chang Gung
Memorial Hospital, Tao, Taipei, Taiwan
Chin-Ho Wong, MBBS, MRCS, (Ed); F.C. Wei; Brian Fu; Ying-An Chen; Jeng-Yee Lin
*10:20am – 10:25am
Reconstruction of Pediatric Cranial Base Defects: A Retrospective
Review of a Single Microsurgeon’s 30-Year Experience
Institution where the work was prepared: Children’s Hospital Boston, Boston, MA, USA
Matthew J. Carty, MD; Nalton Ferraro, MD, DMD; Joseph Upton
*10:25am – 10:30am
Free Serratus Fascia Flap - Anatomic Study & Clinical Application
Institution where the work was prepared: University of California, San Diego, CA, USA
Lars H. Evers, MD; Dhaval Bhavsar; Mayer Tenenhaus; Richard Bodor; Gottfried Lemperle
10:25am – 10:30am
Mandibular Reconstruction using Custom Made Osteotomy Templates
Ryo Hattori, MD; Ken Matsuda; Tateki Kubo; Mamoru Kikuchi; Ko Hosokawa; Sayuri Arimitsu;
Tsuyoshi Murase
10:30am – 10:35am
The Extended ALT Flap: Anatomical Basis and Clinical Experience
Michel Saint-Cyr, MD; Mark Schavarien, MBBS, MRCS; Corrine Wong, MBBS, MRCS; Gary
Arbique, PhD; Puru Nagarkar; Spencer Brown, PhD; Rod Rohrich, MD
*10:30am – 10:35am
Extracranial-Intracranial Bypass. A Case Series
Institution where the work was prepared: Eastern Virginia Medical School, Norfolk, VA, USA
Michael W. Chu, MD; Ran Vijai Singh, MD; J Trad Wadsworth
52
*10:35am – 10:40am
1:50pm – 1:55pm
Wide Combined Thin Free SCIA/SIEA Flap
Institution where the work was prepared: Hacettepe University, Ankara, Turkey
Serdar Nasir, MD; Mustafa Asim Aydin, MD; Tunc Safak, MD; Abdullah Kecik, MD
Three and Four- Dimensional Computer Tomography Angiographic
Studies of Internal Mammary Artery Perforator Flaps
Corrine Wong, MBBS, MRCS; Michel Saint-Cyr, MD; Gary Arbique, PhD; Spencer Brown,
PhD; Rod Rohrich, MD
Withdrawn
1:55pm – 2:00pm
Distally Based Sural Fasciomyocutaneous Flap: Anatomic Study
and Modified Technique for Complicated Wounds of the Lower
Third Leg and Weight Bearing Heel
Institution where the work was prepared: Tongji University, Shanghai, China
Shi-Min Chang, MD; Kai Zhang, PHD
*10:40am – 10:45am
Influencing Flap Survival Rate in a Rat Model via
Pharmaceutical Preconditioning
Institution where the work was prepared: Department of Hand-, Plastic and Reconstructive
Surgery, Ludwigshafen, BG Trauma Center, Germany
Holger Engel, MD; Emre Hakki Gazyakan, MD, ;, MSc; Natalie Desilie; Martha Maria Gebhard,
MD; PhD; Markus Volkmar Küntscher, MD, ;, PhD;; Guenter Germann, MD, PhD;
2:00pm – 2:05pm
Comparison of Different Management of Large Superficial Veins
in Distally Based Fasciocutaneous Flaps with a Veno-Neuro-Adipofascial
Pedicle: An Experimental Study in the Rabbit Model
Institution where the work was prepared: Tongji Hospital, Tongji University, Shanghai, China
Shi-Min Chang, MD; Yudong Gu, MD; Ji-Feng Li
10:45am – 10:50am
Repopulation of Vascularized Bone Allotransplants With Recipient-Derived
Cells: Detection by Laser Capture Microdissection and Real-Time PCR
Michael Pelzer, Dr; Mikko Larsen, MD; Patricia F. Friedrich; Ra Aleff; Allen T. Bishop
10:50am – 10:55am
An Innervated Eyelid Flap for Future Allotransplantation: An Anatomic
Study
David W. Mathes; James Edwards; Peter C. Neligan
*2:05pm – 2:10pm
Risk Analysis for the Reverse Sural Fasciocutaneous Flap in
Distal Leg Reconstruction
Institution where the work was prepared: Brigham & Women’s Hospital, Boston, MA, USA
Brian M. Parrett, MD; Evan Matros, MD; Julian J. Pribaz, MD; Wojtek Przylecki, MD;
Christopher E. Sampson, MD; Dennis P. Orgill, MD, PhD
*10:55am – 11:00am
Thoracic and Lumbar Perforators: Four-Dimensional Vascular Anatomy,
Cluster Analysis, and Implications for Pedicle Perforator Flap Designs
Institution where the work was prepared: UT Southwestern Medical Center at Dallas, Dallas, TX, USA
Kathleen Herbig, MD; Michel Saint-Cyr; Corrine Wong; Gary Arbique; Spencer A. Brown;
Rod J. Rohrich
2:10pm – 2:15pm
Clinical Application of Bone Marrow Stromal Cells to Avascular Necrosis
of the Femoral Head Combined with Vascularized Iliac Bone Graft
Institution where the work was prepared: Department of Orthopedic Surgery, Kyoto University,
Kyoto, Japan
Ryosuke Ikeguchi, MD; Ryosuke Kakinoki, MD, PhD; Tomoki Aoyama, MD, PhD; Koji Goto,
MD, PhD; Taira Maekawa, MD, PhD; Takashi Nakamura, MD, PhD; Junya Toguchida, MD,
PhD
11:00am – 11:30am Presidential Address
2:15pm – 2:20pm
Microsurgical Partial Toe Transfer Combining With the Finger Arterial Flap
Institution where the work was prepared: Saitama Hand Surgery Institute, Saitama, Japan
Yuichi Hirase, MD; Tadao Kojima, MD; Keizo Fukumoto, MD; Mahito Kuwahara, MD
Neil F. Jones, MD
11:30am – 1:30pm
Best Case/Best Save Presentations & Luncheon
Michael Zenn, MD, Moderator
2:20pm – 2:25pm
Unilateral Longitudinal External Pudendal Artery Perforator Flap – A New
Technique for Reconstruction of Congenital Vagina Agenesis
Institution where the work was prepared: Chang Gung Memorial Hospital , Taoyuan, Taiwan
Jung-Ju Huang; Chien-Min Han, MD; Chyi-Long Lee, MD, PhD; Ming-Huei Cheng
The Best Microsurgical Save of the Year Award and the Best
Microsurgical Case of the Year Award will be presented,
based on submissions from the membership of microsurgical
salvage cases performed during the last year. A panel of
experts will critique submitted cases and the attendees will
vote for the best case and the best save.
Lunch will be served
2:25pm – 2:30pm
Experience with the Adductor Magnus Free Flap
Institution where the work was prepared: The University of Texas at Houston, Houston, TX,
USA
Emmanuel G. Melissinos, MD; Donald H. Parks, MD
The ASRM would like to thank Synovis MCA
Supported by:
for their generous support of this event.
1:30pm - 2:30pm
Extremities II
Moderator: L. Scott Levin, MD
1:30pm - 2:30pm
*1:30pm – 1:35pm
Distal Phalanx Replantation Using the Delayed Venous Method:
A High Success Rate in 33 Cases
Institution where the work was prepared: Makoto Mihara, Tokyo, Japan
Makoto Mihara, MD; Mitsunaga Narushima; Isao Koshima
Head and Neck II
Moderator: Joesph J. Disa, MD
*1:30pm – 1:35pm
The Scapular Tip - Angular Artery Free Flap: A New Option in Maxillary
Reconstruction
Nitin A. Pagedar, MD; Rajan S. Patel, MD, FRCS; David P. Goldstein, MD, FRCSC; Jonathan
C. Irish, MD, FRCSC; Dale H. Brown, MD, FRCSC; Patrick J. Gullane, MD, FRCSC; Ralph W.
Gilbert, MD, FRCSC
*1:35pm – 1:40pm
Pediatric Vascular Emergencies: The Need for Microsurgical Expertise
Institution where the work was prepared: Children’s Hospital of Philadelphia & University of
Pennsylvania, Philadelphia, PA, USA
Adam J. Kaye, MD; Alison E. Kaye, MD; Thane A. Blinman, MD; Michael I. Nance, MD;
Patrick K. Kim, MD; Benjamin Chang, MD
*1:35pm – 1:40pm
Microvascular Free Flap Reconstruction Versus Palatal Obturation for
Maxillectomy Defects
Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA
Mauricio A. Moreno; Roman J Skoracki; Ehab Y Hanna; Matthew M. Hanasono, MD
*1:40pm – 1:45pm
The Posterior Tibial Artery Perforator Flap: An Alternative to
Free Flap Closure in the Comorbid Patient
Institution where the work was prepared: Beth Israel Deaconess & Massachusetts General
Hospital, Boston, MA, USA
Brian M. Parrett, MD; Jonathan M. Winograd; Samuel J. Lin, MD; Loren Borud, MD; Amir H.
Taghinia, MD; Bernard T. Lee, MD
*1:40pm – 1:45pm
Long Term Follow Up of Microsurgical Correction of Facial Asymmetry
Institution where the work was prepared: Institute of Reconstructive Plastic Surgery, NYU
Medical Center, New York, NY, USA
Daniel J. Ceradini, MD; Pierre B. Saadeh; John W. Siebert, MD
*1:45pm – 1:50pm
A Novel Subunit Based Approach to Limb Salvage for Foot and
Ankle Wounds with Free Tissue Transfer: A single institutions
10-year experience of 165 free flaps
Institution where the work was prepared: Duke University Medical Center, Durham, NC, USA
Scott T. Hollenbeck, MD; Shoshana Woo, BS; Detlev Erdmann, MD, PhD; Michael, R. Zenn,
MD; L. Scott Levin, MD
*1:45pm – 1:50pm
Versatility of the Radial Forearm Free Flap in Facial Resurfacing
Institution where the work was prepared: New York University Medical Center, New York, NY, USA
Daniel J. Ceradini, MD; Phuong D. Nguyen, MD; Alexes Hazen, MD; Jamie P. Levine, MD
53
1:50pm – 1:55pm
Gastroomental Free Flap Reconstruction of the Head and Neck Neck
Institution where the work was prepared: Virginia Mason Medical Center, Seattle, WA, USA
Stephen Bayles, MD; Richard E. Hayden
*1:55pm – 2:00pm
Recipient Vessels Analysis in Free Flap Reconstruction For
Head and Neck Cancer Patients After Radiotherapy
Institution where the work was prepared: Chang Gung Memorial Hospital-Kaohsiung Medical
Center,, Kaohsiung, Taiwan
Chien-Chung Chen; Yur-Ren Kuo; Yen-Chou Chen; Yun-Ta Tsai; Pao-Yuan Lin; Seng-Feng Jeng
2:00pm – 2:05pm
Anatomical Basis and Clinical Application of the Pedicled
Thoracoacromial Artery Perforator Flap
Institution where the work was prepared: Shanghai Jiao Tong University, 9th People’s Hospital,
Shanghai, China
Yi Xin Zhang, MD; Yee Siang Ong, MRCS, (Edin); Danru Wang; Jun Yang; Detlev Erdmann,
MD; L. Scott Levin, MD
2:05pm – 2:10pm
Aesthetic Scalp Reconstruction After Large Traumatic Defect;
Does the Outcome Justify the Effort?
Institution where the work was prepared: Buncke Clinic, California Pacific Medical Center, San
Francisco, CA, USA
Darrell Brooks; Rudolf F. Buntic
*2:10pm – 2:15pm
Comparison of Scalp and Calvarial Reconstruction with
Regard to Flap Type and Recipient Vessels
Institution where the work was prepared: University of California Los Angeles, Los Angeles,
CA, USA
Brian P. Dickinson, MD; Jaco Festekjian; Otway Louie; Vishad Nabili; Andrew Da Lio; Keith
Blackwell; Peter Ashjian; James Watson; Crisera Christopher
2:15pm – 2:20pm
The Osteocutaneous Radial Forearm Free Flap: A Novel
Implementation For Single Flap Reconstruction of Midface,
Upper Lip Deficiency and Near-Total Nasal Defects
Institution where the work was prepared: New York University Langone Medical Center, New
York, NY, USA
Oren Tepper, MD; Joseph Michaels; Naveen Setty; Jennifer Capla; Nicholas Haddock; Daniel
Ceradini; David Hirsch; Jamie Levine; Pierre Saadeh
2:20pm – 2:25pm
The Fate of Different Reconstructive Modes for Mandibular Ameloblastomas
Institution where the work was prepared: National Taiwan University Hospital, Taipei, Taiwan
Shih-Heng Chen; Yueh-Bih Tang Chen, Ph, D; Jung-Hsien Hsieh; Hung-Chi Chen, MD, FACS
*2:25pm – 2:30pm
The DIEP Flap for Reconstruction of Total Laryngo-Pharyngeal Defects
Institution where the work was prepared: Harbor-UCLA, Torrance, CA, USA
Otway Louie, MD; Brian Dickinson; Jay Granzow; Brian Boyd
2:30pm – 3:45pm
Mini Panels - Additional CME 1 Credit each
In order to conserve time, the Instructional Course format
has slightly changed. This year simultaneous ‘Mini- Panels
lasting 75min each will consist of 3-5 participants
(1M)
Brachial Plexus Challenges & Solutions
Howard M. Clarke, MD, PhD, Moderator
Thomas Carlstedtt, MD
David Chuang, MD
Kazuteru Doi, MD
(2M)
Nerve and Muscle Transfers
Susan Mackinnon, MD, Moderator
Allen Bishop, MD
Thomas Tung, MD
(4M)
Sarcoma Reconstruction
David Chang, MD, Moderator
Peter Cordeiro, MD
Valerae O. Lewis, MD
6:30pm – 10:00pm
ASRM 25th “Silver” Anniversary Celebration
54
DAY-AT-A-GLANCE
Tuesday, January 13, 2009
6:30am – 4:30pm
Speaker Ready Room
Silversword
6:30am – 4:30pm
ASRM Poster Viewing
Silversword
6:30am – 3:00pm
Meeting Services
6:30am – 8:00am
Coffee
Haleakala Gardens
7:00am – 8:15am
ASRM Mini Panels
1T Urogenital Reconstruction
2T Outcome Studies in Microsurgery
3T Maxillomandibular Reconstruction
4T Microsurgery Reconstruction of Hand and Forearm
5T Microsurgery in Academic vs. Private Practive
6T Tissue Engineering in Microsurgery
Maile 1
Haleakala 2 & 3
Pikake 2 & 3
IIima 2 & 3
Maile 2 & 3
Plumeria 2 & 3
8:00am – 9:15am
Breakfast
Haleakala Gardens
8:15am – 9:15am
Business Meeting (members only)
Haleakala 1
9:15am – 10:15am
PANEL: Facial Reanimation: How I Do It
Haleakala 1
10:15am – 11:15am
Concurrent Scientific Paper Sessions
Clinical: Breast
Head and Neck III
Haleakala 1
Haleakala 2 & 3
11:15am – 12:15pm
Concurrent Panel: Algorithms in Breast Reconstruction
Haleakala 1
11:15am – 12:15pm
Concurrent Panel: Evolution of Microsurgical
Reconstruction of the Upper Extremity
Haleakala 2 & 3
12:15pm – 12:30pm
Closing Remarks
Haleakala 1
12:45pm – 1:45pm
ASRM Council Meeting
IIima 2 & 3
1:00pm – 5:00pm
ASRM/ASRT: The Next Level in Reconstructive Transplantation
Haleakala 2 & 3
55
ASRM: Tuesday, January 13, 2009
6:30am – 8:00am
Coffee
7:00am – 8:15am
Mini Panels - Additional CME 1 Credit each
In order to conserve time, the Instructional Course
format has slightly changed. This year simultaneous ‘Mini- Panels lasting 75min each will consist of
3-5 participants
(1T)
10:15am - 11:15am
*10:15am – 10:20am
Achieving Symmetry in Perforator Flap Breast Surgery
Suhail Kanchwala, MD; Reza Miraliakbari, MD; Joseph Serletti
Urogenital Reconstruction
There are numerous ways in which the reconstructive surgeon can interface with urologists, gynecologists and general surgeons in the management of
complex pelvic and urogenital problems. Our mini
panel will address the role of the reconstructive surgeon in restoring anatomy and function following
trauma, tumor ablation, and congenital deformity.
10:20am – 10:25am
New Microsurgical Breast Reconstruction using the Posterior
Medial Thigh (PMT) Perforator Flap
Institution where the work was prepared: Yokohama City University Medical Center,
Yokohama, Japan
Toshihiko Satake, MD; Takashi Ishikawa, MD; Jiro Maegawa, MD; Soko Watanabe, MD;
Takeshi Nishikori, MD; Seiko Ko, MD; Tomohiro Imai, MD; Tomoko Takano, MD
10:25am – 10:30am
Impending Vascular Compromise of Mastectomy Skin Flaps:
a Salvage Option Using a Non De-epithelialized Buried Flap
Institution where the work was prepared: Tel Aviv Medical Center, Tel Aviv, Israel
Yoav Barnea; Shy Stahl; Aharon Amir; Arik Zaretski; Ehud Miller; Jerry Weiss; Schlomo
Schneebaum; Eyal Gur
Lawrence Colen, MD, Moderator
J. Brian Boyd, MD
(2T)
Outcome Studies in Microsurgery
Achilleas Thoma, MD, Moderator
John J. Coleman, MD
Andrea Pusic, MD
(3T)
10:30am – 10:35am
Use of the Posterior Hip Perforator flap for
Microsurgical Breast Reconstruction
Institution where the work was prepared: Center for Restorative Breast Surgery, New Orleans,
LA, USA
Scott Keith Sullivan, MD, FACS; Frank J. DellaCroce; Chris Trahan
Maxillomandibular Reconstruction
This panel will focus on microsurgical reconstruction of the maxilla and mandible. Topics to be covered include bony vs. soft tissue reconstruction optimizing flap design for osseointegrated implants,
preoperative medical modeling for operative planning and image guided surgery.
*10:35am – 10:40am
The Incidence and Perioperative Factors of Pulmonary
Embolism in Breast Reconstruction Patients
Institution where the work was prepared: University of Manitoba, Winnipeg, MB, Canada
Jennifer Lindsay Giuffre, MD; Edward W. Buchel; Thomas E.J. Hayakawa
Matthew Hanasono, MD, Moderator
Roman Skoracki, MD
J. Trad Wadsworth, MD
(4T)
*10:40am – 10:45am
1000 Consecutive Venous Anastomoses Using the
Microvascular Anastomotic Coupler in Breast Reconstruction
Institution where the work was prepared: University of Pennsylvania Health System,
Philadelphia, PA, USA
Shareef Jandali, MD; Stephen J. Kovach; Liza C. Wu; Stephen J. Vega; Joseph M. Serletti
Microsurgery Reconstruction of Hand
and Forearm
Michael Neumeister, MD, Moderator
(5T)
*10:45am – 10:50am
CT Angiography in Planning Abdomen-based Microsurgical
Breast Reconstruction: A comparison to duplex ultrasound
Jeffrey R. Scott, MD; Daniel Liu; Hakim K. Said, MD; Peter C. Neligan; David W. Mathes
Microsurgery in Academic vs.
Private Practice
Microsurgery usually requires an experienced
"team" of surgeons, assistants, and nurses. While
this is readily available in academic practice, it may
not always be so in private practice. This panel will
discuss the pluses and minuses of microsurgery in
private vs. academic practice and what can be
done to make microsurgery a viable part of a private practice
10:50am – 10:55am
Introducing the sc-GAP (septocutaneous gluteal artery perforator flap)
Institution where the work was prepared: MUMC+ Masstricht University Medical Centre,
Maastricht, Netherlands
Stefania Tuinder, MD; Arno Lataster; Tim Leiner, MD; Marga F. Massey, MD; Robert J. Allen,
MD; Rene Van der Hulst, MD, PhD
Gregory R. D. Evans, MD
Neil Fine, MD
(6T)
10:55am – 11:00am
Acquiring Maximum Volume Autogenous Breast Reconstruction
With Stacked/Chimeric DIEP and Posterior Hip Perforator Flaps
Institution where the work was prepared: Center for Restorative Breast Surgery, New Orleans,
LA, USA
Scott Keith Sullivan, MD, FACS; Frank J. DellaCroce, MD, FACS; Chris Trahan
Tissue Engineering in Microsurgery
This panel will discuss the role of tissue engineering in tracheal resonstruction.
Geoffrey Gurtner, MD, Moderator
Wayne Morrison, MD
Ron Yu, MD
8:00am – 9:15am
Breakfast
8:15am – 9:15am
Annual Business Meeting (ASRM members only)
9:15am – 10:15am
Facial Re-Animation: How I do it
In this panel, the technical details of making a facial paralysis reconstruction really work will be discussed. Procedures
ranging from static-slings weights and lifts, to dynamic
regional transfers to microsurgical functioning muscle.
Transplants will be addressed by the experts with plenty of
time for discussion. Not only will the panelist’s technical
secrets be revealed but the place of each technique in the
reconstructive surgeon’s armamentarium will be outlined.
ASRM CONCURRENT
SCIENTIFIC PAPER SESSIONS:
Clinical: Breast
Moderator: Joseph M. Serletti, MD
11:00am – 11:05am
The Transverse Upper Gracilis Flap as an Alternative to
Abdominal Tissue Reconstruction: Technique and Modifications
Institution where the work was prepared: California Pacific Medical Center, San Francisco,
CA, USA
Karen M. Horton, MD, MSc, FRCSC; Rudolf F. Buntic, MD; Darrell Brooks, MD; Matthew
Trovato
11:05am – 11:10am
Septocutaneous Deep Inferior Epigastric Artery
Flap for Breast Reconstruction
Institution where the work was prepared: Medical University of South Carolina, Charleston,
SC, USA
Mary Lester, MD; Robert J Allen; Maria M. LoTempio
11:10am – 11:15am
Lymph Node Transplantation in Breast Reconstruction
using Perforator Flaps
Institution where the work was prepared: Medical University of South Carolina, Charleston, SC, USA
Maria M. LoTempio; Mary E. Lester; Julie Vasile; Marga F Massey; Josh L. Levine; Heather
Erhard; David Greenspun; Robert J Allen
Ralph Manktelow, MD, Moderator
Roger Simpson, MD
Ronald Zuker, MD
56
10:15am - 11:15am
11:15am – 12:15pm
ASRM CONCURRENT
SCIENTIFIC PAPER SESSIONS:
CLINICAL: Head and Neck III
Moderator: Peirong Yu, MD
10:15am – 10:20am
The “Omega-shaped” Fibula Osteocutaneous Free Flap
for Reconstruction of Extensive Mid-facial Defects
Institution where the work was prepared: The University of Texas M. D. Anderson Cancer
Center, Houston, TX, USA
Matthew M. Hanasono, MD; Roman J. Skoracki
Concurrent Panel: Algorithms
in Breast Reconstruction
Many different techniques and approaches are used in
breast reconstruction. The panel will present their own
algorithms addressing: reconstruction of the radiated
breast; the place of alloplastic reconstruction; choice of
donor site - and technique - for autogenous tissue transfer,
and the sequence of secondary surgery.
J. Brian Boyd, MD, Moderator
Elisabeth Beahm, MD
Ed Buchel, MD
Joseph Serletti, MD
10:20am – 10:25am
Restoring the Failed Cranioplasty: Non-Anatomic
Titanium Mesh with Perforator Flap
Institution where the work was prepared: Shock Trauma-Johns Hopkins Medical Center,
Baltimore, MD, USA
Hugo St-Hilaire, MD, DDS; Suhail K. Mithani, MD; Eduardo Rodriguez, MD, DDS
11:15am – 12:15pm
Concurrent Panel:
Evolution of Upper Extremity Reconstruction
Wayne Morrison, MD, PhD, Moderator
Luis Scheker, MD
Susumu Tamai, MD
Fu Chan Wei, MD
10:25am – 10:30am
Microsurgical Reconstruction Of Complex Scalp Defects:
A Retrospective Follow-up Study
Institution where the work was prepared: Dep. plastic surgery, Erasmus MC, Rotterdam,
Netherlands
Marc A.M. Mureau, MD, PhD; Antoinette A. van Driel, MD; Stefan O.P. Hofer, MD, PhD,
FRCS(C)
*10:30am – 10:35am
Definitive Treatment of Persistent Frontal Sinus Infections: Novel
Reconstruction and Complete Sino-Nasal Separation with Fibular Free Flaps
Institution where the work was prepared: R Adams Cowley Shock Trauma Center & Johns
Hopkins University, Baltimore, MD, USA
Helen Hui-Chou; Arthur J. Nam; Matthew G. Stanwix, MD; Hugo St. Hilaire; Oliver P.
Simmons; Paul N. Manson, MD; Eduardo D. Rodriguez
12:15pm – 12:30pm
Closing Remarks
12:45pm – 1:45pm
Council Meeting
1:00pm – 5:00pm
ASRM/ASRT: The Next Level in
Reconstructive Transplantation
Chairs: WP Andrew Lee, MD, Maria Siemionow, MD
1:00pm – 1:15pm
10:35am – 10:40am
Proper Management of Colo-esophageal Junction When
Colon is Used for Reconstruction of Esophagus
Institution where the work was prepared: E-Da Hospital , Kaohsiung , Taiwan
Hung-Chi Chen, MD, FACS; Samir Mardini, MD; Salgado Salgado, MD; Yueh-bih Tang, MD,
PhD
Tricks and Tips for Hand Transplantation
Warren Breidenbach, MD, Louisville, KY, USA
1:20pm –1:35pm
World’s First Arm Transplantation
1:40pm –1:55pm
Reconstructive Transplantation: The Surgical
Challenges Ahead
Christoph Hoehnke, MD, Munich, Germany
TBD
*10:40am – 10:45am
Comparison of Radial Forearm Flaps and Medial Sural
Artery Perforator Flaps for Head and Neck Reconstruction
Institution where the work was prepared: Ching-Chun Lin, Taipei, Taiwan
Ching-Chun Lin, Resident, MD; Chang-Cheng Chang; Ming-Huei Cheng, MD; Fu-Chan Wei,
professor; Huang-Kai Kao, MD
2:00pm – 2:15pm
Face Transplantation: Principles of Planning,
Execution and Postoperative Care
Laurent Lantieri, MD, Paris, France
2:20pm – 2:35pm
*10:45am – 10:50am
Sub-Total Thigh Perforator Free Flap for Coverage
of Large Soft-Tissue Defects
Institution where the work was prepared: University of Chicago, Chicago, IL, USA
Neta Adler, MD; Al B. Cohn, MD; Mark Villa, MD; Jayant P. Agarwal, MD; Lawrence J.
Gottlieb
The Realization of Transplantation Tolerance
with Vascularized Bone Marrow: Ready for
Prime Time?
Maria Siemionow, MD, Cleveland, OH, USA
2:40pm – 2:55pm
*10:50am – 10:55am
Outcome Comparisons between Soft-tissue Flaps and Bone-carrying
Flaps for Reconstruction of Cordeiro Type II and IIIa Maxillectomy
Defects Following Oncological Resection
Chih-Wei Wu, MD; Jung-Ju Huang; Huang-Kai Kao; Chung-Kan Tsao; Ming-Huei Cheng
Visualization Strategies, Preoperative
Planning and Virtual Surgery in
Darren Smith, MD, Pittsburgh, PA, USA
*10:55am – 11:00am
Perforator Topography of the Medial Sural Perforator Flap
and Clinical Application in Head and Neck Reconstruction
Ying-an Chen, MD; Huang-Kai Kao, MD; Ming-Huei Cheng, MD; Fu Chan Wei, MD, FACS
3:00pm – 3:15pm
Break
3:15pm – 3:45pm
Free Papers
Chairs: David Mathes, MD, Christoph Hoehnke, MD
3:45pm– 3:55pm
11:00am – 11:05am
Osseointegrated Dental Implants in Patients with Head and Neck Cancer
Institution where the work was prepared: The University of Texas M. D. Anderson Cancer
Center, Houston, TX, USA
Matthew M. Hanasono, MD; Roman J. Skoracki, MD; Martina Ayad, BS; Neha Goel, BS;
Rhonda Jacob, DDS; Suyu Liu, MS; Peirong Yu, MD
Introducing the American Society for
Stefan Schneeberger, MD, Pittsburgh, PA, USA
3:55pm – 4:30pm
Expert Panel
Prosthetics vs. Transplantation vs. Tissue Engineering:
Strength and Weaknesses and the Center for the
Upper Limb Amputee of the Future
Chairs: Neil Jones, MD; Scott Levin, MD; Marc Schieber, MD, The
Case for Prostetics; David Mathes, MD, The Case for Allotransplantation;
Wayne Morrison, MD, The Case for Tissue Engineering
11:05am – 11:10am
Microvascular Reconstruction of Mandible Defects Due to Gunshot Injuries
Selçuk Isik; Ismail Sahin; Mustafa Nisanci; Serdar Ozturk; Mustafa Deveci; Cengiz Acikel
*11:10am – 11:15am
Tongue Reconstruction With Free Tissue Transfer:
An experience with 110 cases
Holger Engel, MD; Emre Gazyakan, MD, MSc; Jung-Ju Huang, MD; Shu-Ying Chang, MD;
Ming-Huei Cheng, MD, MHA
4:30pm – 4:50pm
Keynote Address:
When Less is More
Thomas E. Starzl, MD, Pittsburgh, PA, USA
57
ABSTRACT TABLE OF CONTENTS
AAHS/ASPN/ASRM Author Indexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59-60
AAHS Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61-83
AAHS Poster Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84-90
ASPN Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91-114
ASPN Poster Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115-119
ASRM Abstracts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120-173
ASRM Poster Presentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174-194
58
ABSTRACT AUTHOR INDEX
A
Abe, Koji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Abidian, Mohammad Reza . . . . . . . . . . . . . . . . . 102, 103
Abzug, Joshua . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Acikel, Cengiz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Adler, Neta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176, 177
Agaoglu, Galip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Agarwal, Jayant P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Ahlborg, Henrik G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Aizer, Ayal A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Aktepe, Fatma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Al-Attar, Ali . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Alam, Daniel . . . . . . . . . . . . . . . . . . . . . . . . 141, 180, 186
Aleff, Ra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Allen, Robert J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Amir, Aharon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Amrami, Kimberly . . . . . . . . . . . . . . . . . . . . . . . . 106, 109
An, Kai-Nan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61, 71
Anastakis, Dimitri J. . . . . . . . . . . . . . . . . . 77, 94, 98, 111
Anderson, Meredith L. . . . . . . . . . . . . . . . . . . . . . . . . . 106
Anton, Martina: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Aoyama, Tomoki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Araki, Jun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77, 134
Arbique, Gary . . . . . . . . . . . . . 144, 145, 147, 184, 192
Ardelean, Filip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Arimitsu, Sayuri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Arruda, Eric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Ashjian, Peter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Atroshi, Isam . . . . . . . . . . . . . . . . . . . . . . . . . . 62, 74, 88
Attinger, Christopher . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Ayad, Martina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Aydin, Mustafa Asim . . . . . . . . . . . . . . . . . . . . . . 156, 178
B
Badalamente, Marie . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Badia, Alejandro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Bansal, Anshuman . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Bar-Meir, Eran D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Barnea, Yoav . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165, 187
Barth, Rolf N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Bartlett, Stephen T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Bayles, Stephen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Beaton, Dorcas E. . . . . . . . . . . . . . . . . . . . . . . . . . . . 77, 94
Bednar, Michael S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Bellan, Leon M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Bellivier, Franck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Belzberg, Allan J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Benjoar, Marc David . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Bergey, Meredith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Berglund, Lawrence J. . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Bergonsi, Tomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Bernard, Steven . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
Bernier, C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Berry, Nada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Bezuhly, Michael . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Bhavsar, Dhaval . . . . . . . . . . . . . . . . . . . . . . . . . . 144, 182
Bidic, Sean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Billsten, Mats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Bishop, Allen T. . . . . . . . . . . . . . . . . . . . . . . . . . . 139, 145
Blackwell, Keith . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Blair, B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Blinman, Thane A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Blok, Joleen H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Bodor, Richard . . . . . . . . . . . . . . . . . . . . . . . . . . . 144, 182
Borrero, Camilo D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Borschel, Gregory . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Borud, Loren . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Bossers, Koen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Bottino, Clement J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Boyd, Brian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Braga-Silva, Jefferson . . . . . . . . . . . . . . . . . . . . . . 126, 131
Breidenbach, Wc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Brill, Thomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Brooks, Darrell . . . . . . . . . . . . . . 151, 161, 167, 187, 193
Brown, Dale H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Brown, David L. . . . . . . . . . . . . . . . . . . . . . . . . . . 112, 121
Brown, Justin M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Brown, Michael . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62, 88
Brown, Spencer A. . . . . . . . . . . . . . . . 144, 145, 147, 184
Brzezicki, Grzegorz . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Buchel, Edward W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Buell, Jf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Buffington, Deborah . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Buntic, Rudolf F. . . . . . . . . . . . . . . . . . . . . . . 138, 161, 167
Buntic, Rudy F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Busnardo, Fabio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Butler, Charles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
C
Cannady, Steven . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Capla, Jennifer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Capota, Irina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Carlsen, Brian T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74, 77
Carmichael, Stephen W. . . . . . . . . . . . . . . . . . . . . . . . . 109
Carty, Matthew J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Caruelle, Jean Pierre . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Ceradini, Daniel J. . . . . . . . . . . . . . . . . . . . . 132, 159, 160
Chang, Benjamin . . . . . . . . . . . . . . . . . . . . . . . . . 129, 154
Chang, Chang-Cheng . . . . . . . . . . . . . . . . . 171, 183, 185
Chang, Christopher C. . . . . . . . . . . . . . . . . . . . . . . . . . 123
Chang, David C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Chang, Edward I. . . . . . . . . . . . . . . . . . . . . . . . . 121, 122
Chang, James . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64
Chang, Shi-Min . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156, 157
Chang, Shu-Ying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173, 186
Chen, Hung-Chi . . . . . . . . . . . . 139, 149, 163, 170, 175, 176
Chen, Ruei-Feng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Chen, Shih-Heng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Chen, Yen-Chou . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Chen, Ying-An . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Chen, Zeng-Gan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Cheng, Jonathan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Cheng, Ming-Huei . . . . 148, 158, 171, 172, 173, 183, 185, 186, 187
Chiang, Yuan-Cheng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Cho, Alvaro B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Cho, Younghoon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Chollet, A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Christopher, Crisera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Christy, Michael R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Chu, Michael W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Chuang, Chwei-Chin . . . . . . . . . . . . . . . . . . . . . . . . . . 183, 185
Clarke, Howard M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Cobb, Tyson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Cohen, Meghan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Cohn, Al B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Cole, W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Coleman, Stephen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Collins, Brendan J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Connor, Nadine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Constantinescu, Mihai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Cook, Nicholas J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Cooney, William P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Corey, Joseph M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Costas, Bronier L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Craighead, Harold G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Currie, R. William . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Curtis, Christine G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Cwykiel, Joanna . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Cypel, T.K.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140, 174
G
J
Gagnon, A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Jacob, Rhonda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Ganal, Edton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Jaeger, Marcos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126, 131
Gangopadhyay, Noopur . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Jandali, Shareef . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Garfein, Evan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Jeng, Seng-Feng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Gatherwright, James . . . . . . . . . . . . . . . . . . . . . . . . . 106, 123
Jobin, Charles M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Gazyakan, Emre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173,186
Jones, Seth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 107
Gazyakan, Emre Hakki . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Jordan, Elizabeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Gebhard, Martha Maria . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Jupiter, Jesse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67, 69
Georgescu, Alexandru . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Juskevicius, Ridas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Gerstle, Justin T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Gharb, Bahar Bassiri . . . . . . . . . . . . . . . . . . . . . 149, 175, 176
Gilbert, Ralph W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Giuffre, Jennifer Lindsay . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Giunta, Riccardo E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Goel, Neha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Gohritz, Andreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
Goitz, Robert Joseph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Goldstein, David P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Gordon, T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Gordon, Tessa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Goto, Akira . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Goto, Koji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Goto, Shigeru . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
D
Da Lio, Andrew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Dalal, Neil D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Daneshvar, Eugene Dariush . . . . . . . . . . . . . . . . . . . . . . . . 102
Dauwe, Phillip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
David, William S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Davis, Karen D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Davison, Steven Paul . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188
Day, Charles S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75, 82
De Boer, Ralph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
De la Garza, Mauricio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Deftereos, Spyridon . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 113
DellaCroce, Frank J. . . . . . . . . . . . . . . . . . . . . . . . . . . 165, 167
Dellon, A. Lee . . . . . . . . . . . . . . . . . . . . . . . . . 73, 95, 105, 114
Demir, Yavuz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Denis, Barritault . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Dennison, David G. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Derwin, Kathleen A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Desilie, Natalie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Desy, Nicholas M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Deune, E. Gene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Deveci, Mustafa . . . . . . . . . . . . . . . . . . . . . . . . . 132, 172, 185
Diamond, Ivan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Dickinson, Brian P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Djohan, Risal . . . . . . . . . . . . . . . . . . . . . . . 137, 141, 180, 186
Dorsi, Michael J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Ducic, Ivica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109, 136
Duffy, John M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Duggan, William . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Dumanian, Gregory A. . . . . . . . . . . . . . . . . . . . . . . . . 118, 131
Dunn, Reg . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Duymaz, Ahmet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75, 135
K
Kakinoki, Ryosuke . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79, 157
Kalén, Peter . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Kanchwala, Suhail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Kandal, Sebahattin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Kao, Huang-Kai . . . . . . . . . . . . . . . . . . . . . 171, 172, 183, 185
Karabekmez, Furkan Erol . . . . . . . . . . . . . . . . . . . . 61, 75, 135
Karlsson, Magnus K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Kasukurthi, Rahul . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 115
Katz, Joel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77, 94
Kaufman, C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Kaufmann, Robert Alexander . . . . . . . . . . . . . . . . . . . . . . . . . 81
Kawakita, Astuo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Kaye, Adam J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Gottlieb, Lawrence J. . . . . . . . . . . . . . . . . . . . . . . . . . . 171, 177
Kaye, Alison E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Goyal, Namita A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Kecik, Abdullah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156, 178
Granick, Mark S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Kemp, Stephen W.P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Grant, D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Kerr-Valentic, Mahlon Alder . . . . . . . . . . . . . . . . . . . . . . . . . 142
Granzow, Jay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Ki, Sae H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64
Graves, Scott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Kiehn, Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Greenspun, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Kikuchi, Mamoru . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Grimbert, Philippe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Kim, David C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Gu, Yu-Dong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Kim, Patrick K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Guertin, C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Kim, Peter S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 99, 131
Gullane, Patrick J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Kim, Sendia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Gummesson, Christina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Kinnas, Panagiotis Athanasiou . . . . . . . . . . . . . . . . . . 100, 113
Gur, Eyal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165, 187
Kipke, Daryl R. . . . . . . . . . . . . . . . . . . . . . . . 96, 102, 103, 112
Gutmark, Ron . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Kircher, Michelle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Gänsbacher, Bernd . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Klimczak, Aleksandra . . . . . . . . . . . . 106, 108, 123, 143, 179
Klumb, Ivette . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Knight, Andrew M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
H
Haddock, Nicholas . . . . . . . . . . . . . . . . . . . . . . . . . . . 132, 162
Hadlock, Tessa A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Hall, Stephen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Hammel, Nathan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Han, Chien-Min . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Hanasono, Matthew M. . . . . . . . . . . . . . . 159, 169, 172, 179
Hanlin, Sandy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Harris, Patrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .88, 133
Hartig, Gregory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Hasuo, Takaaki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Hattori, Ryo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Hayakawa, Thomas E.J. . . . . . . . . . . . . . . . . . . . . . . . 165, 187
Hayden, Richard E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Hazen, Alexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Knobloch, Karsten . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134, 176
Ko, Jason H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 99, 131
Ko, Seiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Kochevar, Irene E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Kocsis, Jeffery D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Kojima, Tadao . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Koshima, Isao . . . . . . . . . . . . . . . . . . . . . . . . . . 181, 182, 189
Kosins, Aaron M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Kovach, Stephen J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Kowalchuk, Deborah . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Kraisarin, Jirachart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Krokowicz, Lukasz . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Kroonen, Leo T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Kubo, Tateki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101, 150
Kuhn, Kevin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Heaton, James T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Kuiken, Todd A. . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 99, 131
Henry, Francis Patrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Kulahci, Yalcin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Hentz, Vincent R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Kuo, Yur-Ren . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Herbig, Kathleen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Kuwahara, Mahito . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Hernandez, Anatoly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Kuzon Jr, William M. . . . . . . . . . . . . . . . . . . . . . . 96, 106, 112
Herold, Christian B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Küntscher, Markus Volkmar . . . . . . . . . . . . . . . . . . . . . . . . . 145
Higgins, James Patrick . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
E
Edwards, James . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Egeland, Brent M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
El-ftesi, Samyra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121, 122
Elliott, River . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Engel, Holger . . . . . . . . . . . . . . . . . . . . . . . . . . . 145, 173, 186
Erdmann, Detlev . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155, 161
Erhard, Heather . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Esquivel, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Evans, Gregory RD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Evans, Peter J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Evers, Lars H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144, 182
Hirase, Yuichi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
L
Hirsch, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Lacovara, Alicia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Hivelin, Mikael . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Ladak, Adil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Hiyashi, Ayato . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Langevin, Claude-Jean . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Hofer, Stefan O.P. . . . . . . . . . . . . . . . . . . . 170, 180, 181, 186
Lankford, Karen L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Hofmeister, Eric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Lantieri, Laurent A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Hollenbeck, Scott T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Larkin, Lisa M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Holzbach, Thomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Larsen, Mikko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139, 145
Horton, Karen M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Lataster, Arno . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Hosokawa, Ko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101, 150
Lawton, Jeffery N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Hotchkiss, Robert N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Houlden, David A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Hovius, Steven E.R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Hsieh, Jung-Hsien . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Huang, Jung-Ju . . . . . . . . . . . . . . . . 171, 173, 183, 185, 186
Hui-Chou, Helen
F
Faria, Jose Carlos . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Fazl, Mahmood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Fecteau, A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Ferguson, John Scott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Ferraro, Nalton . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Ferreira, Marcus Castro . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Festekjian, Jaco . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Filippidis, Theodoros . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 113
Fitzgerald, Brian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Fitzmaurice, Michael . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Flondell, Magnus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Franco, Johnny . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Friedrich, Patricia F. . . . . . . . . . . . . . . . . . . . . . . . . . . . 139, 145
Fritz, Michael . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Fu, Brian . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Fujiwara, Toshihiro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Fukumoto, Keizo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Humes, H. David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Hunter, Daniel A. . . . . . . . . . . . . . . . . . . . . . . . . 109, 111, 119
Hurst, Lawrence C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Hyde, James . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 107
I
Ikegami, Hiroyasu . . . . . . . . . . . . . . . . . . . . . . . . . . . 69, 78, 93
Ikeguchi, Ryosuke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157, 79
59
Lax, Matthew J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Le, Elizabeth N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Lecours, Catherine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Lee, Bernard T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140, 155
Lee, Chyi-Long . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Lee, Raphael C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Lee, W.P. Andrew . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Leiner, Tim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Lemke, Jon . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Lemperle, Gottfried . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Lerman, Oren Z. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Lester, Mary E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Levin, L. Scott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155, 161
Levine, Jamie P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123, 160
Levine, Josh L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Ilyas, Asif M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Li, Ji-Feng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Imai, Tomohiro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Li, Rupeng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 107
Irish, Jonathan C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Lifchez, Scott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Irrgang, James . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Lin, Cheng-Hung . . . . . . . . . . . . . . . . . . . . 127, 188, 189, 192
Isaacs, Jonathan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Lin, Chih-Hung . . . . . . . . . . . . . . . . . . . . . . . . . . 127, 134, 188
Isaxon, Ingrid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Lin, Ching-Chun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Ishikawa, Takashi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Lin, Jeng-Yee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144, 148
Isik, Selçuk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Lin, Jenny C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98, 129
ABSTRACT AUTHOR INDEX
Lin, Lin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Lin, Pao-Yuan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Lin, Samuel J. . . . . . . . . . . . . . . . . . . . . . . . . . . . 135, 149
Lin, Yu-Te . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188, 189
Lindsey, Derek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64
Lineaweaver, William . . . . . . . . . . . . . . . . . . . . . . . . . 142
Liu, Daniel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Liu, Suyu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Liwski, Robert S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Ljunggren, Östen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Lo, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Lohman, Robert . . . . . . . . . . . . . . . . . . . . . 137, 141, 186
Loizides, Photis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Longaker, Michael T . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Lorenz, Robert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
LoTempio, Maria M. . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Louie, Otway . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162, 163
Lu, Jiu-Zhou . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Lu, Ting-Chen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
Lubahn, John D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78, 81
Luciano, Janina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Luthra, Gauri . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Lyrén, Per-Erik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Lytle, Ian F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
M
Machens, Hans-Günther . . . . . . . . . . . . . . . . . . . . . . . . 102
Mackinnon, Susan E. . . . . . 108, 110, 111, 114, 115, 119
Maegawa, Jiro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Maekawa, Taira . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Magill, Christina M. . . . . . . . . . . . . . . . . . . . 108, 109, 119
Mahoney, P. Stephen . . . . . . . . . . . . . . . . . . . . . . . . 62, 88
Mailhot, Emile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Makhni, Eric . . . . . . . . . . . . . . . . . . . . . . . . . . . 75, 82, 87
Malessy, Martijn J.A. . . . . . . . . . . . . . . . . . . 93, 102, 103
Manders, Ernest K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Manson, Paul N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Marcelo, Cynthia L. . . . . . . . . . . . . . . . . . . . . . . . 112, 135
Mardini, Samir . . . . . . . . . . . . . 139, 149, 170, 175, 176
Martin, David C. . . . . . . . . . . . . . . . . . . 96, 103, 106, 112
Martins, Pedro Escobar . . . . . . . . . . . . . . . . . . . . . . . . . 126
Marvin, M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Massey, Marga F. . . . . . . . . . . . . . . . . . . . . . . . . . 166, 168
Matei, Ileana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Mathes, David W. . . . . . . . . . . . . . . . . . . . . 120, 146, 166
Matiasek, Kaspar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Matloub, Hani . . . . . . . . . . . . . . . . . . . . . . . . . . . 107, 184
Matros, Evan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140, 157
Matsuda, Ken . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Matsumoto, Taiichi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
McCabe, Steven J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
McDaniel, Candice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
McLain, Robert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Means, Kenneth R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Medoro, Amanda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Meilik, B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Melissinos, Emmanuel G. . . . . . . . . . . . . . . . . . . . . . . . 158
Mellström, Dan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Melvin, Melissa E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Meningaud, Jean Paul . . . . . . . . . . . . . . . . . . . . . . . . . 152
Menon, Nathan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Mensch, Janine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Mercer, Deana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Michaels, Joseph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Midha, Rajiv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97, 107
Mihara, Makoto . . . . . . . . . . . . . 134, 154, 181, 182, 189
Milks, Ryan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Miller, Ehud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Milojcic, Rupprecht . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Miraliakbari, Reza . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Miriani, Rachel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Mirza, Ather . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Mithani, Suhail K. . . . . . . . . . . . . . . . . . . . . . . . . 152, 169
Mitra, Amitabha . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Miwongtum, Tiffany . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Miyake, Junichi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Mok, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Moore, Amy M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Moore, Thomas J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Moran, Steven L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Moreno, Mauricio A. . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Moritomo, Hisao . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Morris, Steven F . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Munoz, Alejandro . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Murase, Tsuyoshi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Mureau, Marc A.M. . . . . . . . . . . . . . . . . . . 170, 180, 181
Murphy, Michael S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Myckatyn, Terence M. . . . . . . . . . . . . . . . . . 108, 109, 193
N
Nabili, Vishad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Nagarkar, Purushottam . . . . . . . . . . . . . . . . . . . . 128, 144
Nagubandi, R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Nair, Dileep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Nakamichi, Noriaki . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Nakamura, Takashi . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Nakamura, Toshiyasu . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Nam, Arthur J. . . . . . . . . . . . . . . . . . . . . . . . . . . . 170, 189
Nance, Michael I. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Narushima, Mitsunaga . . . . . . . . . . . . . . . . 134, 154, 182, 189
Narushima, Narushima . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Nasir, Serdar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123, 178
Neligan, Peter C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Nelson, Jonas A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Neumeister, Michael W. . . . . . . . . . . . . . . . . . . . . . . . . 95, 116
Nguyen, Phuong D. . . . . . . . . . . . . . . . . . . . . . . . . . . . 123, 160
Nikolis, Andreas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88, 133
Nisanci, Mustafa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172, 185
Nishi, Genzaburo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Nishikori, Takeshi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Novak, Christine B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77, 94
Ntouvali, Eleni . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 113
Nyame, Theodore T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Saunders, Rebecca J.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
V
Scharpf, Joseph. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Van der Hulst, Rene . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Schaverien, Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Van Driel, Antoinette A. . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Schembri, P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Van Neck, J.W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Schneck, Carson . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Varshney, Anubodh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Schneebaum, Schlomo . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Scholz, Thomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Schwartz, Michael L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Schwentker, Ann R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Scott, Jeffrey R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
O
O’Shaughnessy, Kristina D. . . . . . . . . . . . . . . . . . . . . . . 99, 131
Obara, Yukihiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71, 82
Ogawa, Kiyohisa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Ohlsson, Claes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Oka, Kunihiro . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Okazaki, Masato . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78, 93
Olivan, Marcelo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Olson, J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Ong, Yee Siang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Orenstein, Harry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Orgill, Dennis P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Ortonne, Nicolas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Osterman, A. Lee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Ozturk, Serdar . . . . . . . . . . . . . . . . . . . . . . . . . . 132, 172, 185
Ozyurekoglu, Tuna . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79, 104
Ozzelie, Rebecca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Vasile, Julie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
Vega, Stephen J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Veitch, John . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Venn-Watson, Eric . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Selber, Jesse Creed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Verge, Valerie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Sena, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Verhaagen, Joost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Serletti, Joseph M. . . . . . . . . . . . . . . . . . . . 137, 164, 166, 180
Vial, Ivan N . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Setty, Naveen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Villa, Mark . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Sharma, Joy V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Vogt, Peter M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176
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Vögelin, Esther . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
Shimada, Kozo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Shin, Alexander Y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74, 77
Shipley, Steven . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141, 189
Shrestha, Jayan Man. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Sideris, Michalis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 113
Siebert, John W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Siemionow, Krzysztof . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
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P
Pagedar, Nitin A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Panagopoulos, Grigorios . . . . . . . . . . . . . . . . . . . . . . . 100, 113
Panossian, Andre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Papalois, Apostolos . . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 113
Parikh, Pranay M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Parisi, Thomas J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Park, Julie E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Parks, Donald H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Parrett, Brian M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155, 157
Parsadanian, Alexander . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Patel, Rajan S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Pawela, Christopher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Pelzer, Michael . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Perlyn, Chad A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Persons, Barbara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Pettersson, L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Pham, Hung M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64
Pirela-Cruz, Miguel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Pirouzmand, Farhad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Pondaag, Willem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Pribaz, Julian J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Przylecki, Wojtek . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Wadsworth, J Trad . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Walsh, Sarah K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Wang, Danru . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Wang, Feng-Sheng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Wang, Huan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Singh, Ran Vijai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Wang, Theresa Y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Singh, Sunil P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Warren, Stephen M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Skinner, John A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Watanabe, Soko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Skoracki, Roman J. . . . . . . . . . . . . . . . . . . 169, 172, 159, 179
Watson, James . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Smit, Xander . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Weber, Renata V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Sobol, Gregory V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Wei, David H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Solowski, Nancy. . . . . . . . . . . . . . . . . . . . . . . . . 100, 111, 119
Wei, F.C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Sonnad, Seema. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Souer, J. Sebastiaan . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67, 69
Spanio di Spilimbergo, Stefano . . . . . . . . . . . . . 139, 175, 176
Spears, Julia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Weichman, Katie . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Weiss, Jerry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Weiss-Meilik, A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Wes, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Spector, Jason A.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
West, Kenneth A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Spies, Marcus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Whitlock, Elizabeth L. . . . . . . . . . . . . . . . . . . . . . . . 108, 119
Spinner, Robert J.. . . . . . . . . . . . . . . . . . 74, 91, 102, 106, 109
Willems, Wouter F. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
St-Hilaire, Hugo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152, 169
Williams, Eric H. . . . . . . . . . . . . . . . . . . . . . . . . . . 73, 84, 88
St-Supéry, V. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Wilson, Christopher J. . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Stahl, Shy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Windebank, Anthony J. . . . . . . . . . . . . . . . . . . . . . . . 91, 102
Stanwix, Matthew G. . . . . . . . . . . . . . . . . . . . . . . . . . 170, 189
Winograd, Jonathan M. . . . . . . . . . . . . . . . . . . . . . . . . . .155
Sterbank, Patrick T. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Wolkenstein, Pierre . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Stewart, Craig P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Storb, Rainer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Strauch, Robert J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Stubenitsky, Bart M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Sugamoto, Kazuomi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Sullivan, Scott Keith. . . . . . . . . . . . . . . . . . . . . . . . . . . 165, 167
R
Rad, Ariel N. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Radtke, Christine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Raizman, Noah M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Rajadas, Jayakumar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Rames, Mattar Júnior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Ramirez, MD, Miguel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Rampazzo, Antonio . . . . . . . . . . . . . . . . . . 139, 149, 175, 176
Randolph, Mark A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Raskin, Keith B. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Ravindra, Kv . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
Ray, Wilson Z. . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 111, 119
Razfar, Ali . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Redmond, Robert W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Rettig, Michael E. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Richardson-Burns, Sarah M. . . . . . . . . . . . . . . . . . . . . . 96, 112
Ring, David . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67, 69
Robertson, Samantha L. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Rodrigues, Mónica . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Rodriguez, Eduardo D. . . . 114, 133, 141, 152, 169, 170, 189
Rodriguez, Sergio . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Rohde, Rachel S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Rohrich, Rod J. . . . . . . . . . . . . . 128, 144, 145, 147, 184, 192
Roman, Javier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Rosenwasser, Melvin P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Rosson, Gedge D. . . . . . . . . . . . . . . . . . . . . . . . . 114, 133, 141
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Russell, John . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Russell, Robert C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95, 116
Wachtman, Galen S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Simmons, Oliver P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Sonmez, Erhan. . . . . . . . . . . . . . . . . . . . . . . . . . 123, 178, 179
Q
Qiu, Yan-Qun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
W
Wong, Alex K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
Wong, Chin-Ho . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Wong, Corrine . . . . . . . . . . . . 76, 128, 144, 145, 147, 184
Wong, Marcus TC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Wong, Sarah Hew-Ming . . . . . . . . . . . . . . . . . . . . . . . . . 127
Woo, Shoshana . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
T
Wright, Melissa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Taghinia, Amir H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Wu, Chih-Wei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Takada, Naoya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Wu, Liza C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Takano, Tomoko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Wunsche, Gerrit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Takeyasu, Yukari . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Tan, Lynn PL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
X
Tan, Suan Cheng. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Xu, Jian-Guang . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Tang Chen, Yueh-Bih . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Tang, Yueh-bih . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Tannemaat, Martijn R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Tapp, Stephanie. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Taras, John S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73, 81
Xu, Lei . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Xu, Wen-Dong . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Y
Tardif, M. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Yamabe, Eiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Tay, Shian Chao . . . . . . . . . . . . . . . . . . . . . . . . 65, 71, 84, 115
Yamamoto, Yusuke . . . . . . . . . . . . . . . . . . . . . 134, 182, 189
Taylor, Keri S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Yan, Ji-Geng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94, 107
Tekin, Levent . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Yan, Ying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108, 109
Tenenhaus, Mayer. . . . . . . . . . . . . . . . . . . . . . . . . . . . 144, 182
Yang, Jun . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Tepper, Oren . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Yang, Ying . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Thakar, Hema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Yano, Kenji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Thanik, Vishal . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Yazici, Ilker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Thoder, Joseph J. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Thompson, Michael . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Thompson, Scott . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Tobias, Adam M.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Tochigi, Hirokazu. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Toguchida, Junya . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Tong, Alice Y. . . . . . . . . . . . . . . . . . . . . . . . . . . . 100, 108, 109
Yee, Andrew X. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Yeh, BA, Albert . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Yoshida, Hirofumi . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Yoshikawa, Hideki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Yu, Peirong . . . . . . . . . . . . . . . . . . . . . . . 127, 148, 172, 179
Yueh, Janet H. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Towers, Jeffrey D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
S
Saadeh, Pierre B. . . . . . . . . . . . . . . . . . . . . . . . . 132, 159, 162
Saba, Salim C. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Saber, Sepideh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64
Safak, Tunc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Safaz, Ismail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Sahin, Ismail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172, 185
Said, Hakim K. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Saint-Cyr, Michel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184, 192
Sakellarides, Harilaos T. . . . . . . . . . . . . . . . . . . . . . . . . . . 85, 93
Salgado, Christopher J. . . . . . . . . . . . . . . . 139, 149, 175, 176
Salgado, Salgado . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Sampson, Christopher E. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Sancaktar, Nazli . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Sassu, Paolo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Satake, Toshihiko . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Sato, Kazuki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78, 93
Satou, Kazuki . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Toyama, Yoshiaki. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Z
Trahan, Chris . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165, 167
Zamboni, William A. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Traub, Matthias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Zamora, Abigail . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Trovato, Matthew J. . . . . . . . . . . . . . . . . . . . . . . 138, 167, 187
Zaretski, Arik . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165, 187
Tsai, Yun-Ta . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Zenn, Michael, R. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Tsao, Chung-Kan . . . . . . . . . . . . . . . . . . . . 171, 183, 185, 187
Zhang, Andrew Y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63, 64
Tsoi, Kim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Tuinder, Stefania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
Tung, Thomas HH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98, 111
Turhan Haktanir, Nurten . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
Tyreman, Neil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104, 113
60
Zhang, Feng . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Zhang, Kai . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
Zhang, Yi Xin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Zhang, Zhen-du . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Zhao, Kristin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
U
Zochodne, Douglas W. . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Unal, Sakir . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Zor, Fatih . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132, 185
Upton, Joseph . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Zuijdendorp, H. Mischa . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Urbanchek, Melanie G. . . . . . . . . . . . . . . . . 96, 102, 106, 112
Zuker, Ronald M. . . . . . . . . . . . . . . . . . . . . . . . . . . . 140, 174
AAHS Concurrent Scientific Paper Session A-1
The Use of Pyrolytic Carbon for the Treatment of Complex Post Traumatic Arthritis
and Acute Joint Loss in the MCP and CMC Joint
Furkan Erol Karabekmez, MD; Ahmet Duymaz, MD; Steven L. Moran; Mayo Clinic
Introduction:
Preservation of joint motion in cases of acute joint destruction and post-traumatic arthritis are challenging problems for surgeon. Previous options for preserving joint motion have included silicone and soft tissue interpositional arthroplasty. Pyrocarbon arthroplasty has been recently introduced as another option. We
wished to examine our intermediate outcomes with the use of pyrocarbon complete and hemi-arthroplasty for the treatment of acute traumatic joint loss and
post-traumatic arthritis.
Material and Method:
From May 2003 to August 2007, 6 MCP and 3 CMC joint pyrolytic carbon metacarpophalangeal implants were inserted in 6 patients. Two patients underwent complete MCP arthroplasty, 3 patients underwent CMC hemiarthroplasty, and 1 patient underwent acute hemiarthroplasty of the small finger. Charts were reviewed for final
range of motion (ROM), pinch and grip strength. Post-operative complications were noted. Hand radiographs were reviewed for signs of implant loosening, migration
and subsidence. Visual analog scale (VAS) scores were used to assess postoperatively pain.
Results:
All patients were male manual laborers with an average age 47 years. Follow-up averaged 36 months. None of the joints required removal. There were no cases of
post-operative subsidence, loosening or implant facture. Pre-operative motion in the two patients with post-traumatic MP arthritis was 15 degrees, post-operative MP
ROM was 65.8 degree and this change was found to be significant (p<0.05). Mean CMC radial abduction angle and palmar abduction angle were 38.3 and 40
degree respectively in CMC arthroplasty cases. There was no statistical difference in radial or palmar abduction angles of CMC joints pre and post-operatively and no
significant difference was seen when compared to the contra lateral normal hands. Statistically significant improvement was found between grip strength of the CMC
joints pre and postoperatively (p<0. 05). Average post-operative VAS (scale 1-10) was 0 in cases of MCP arthroplasty and 1 in cases of CMC arthroplasty. All patients
returned to previous employment.
Conclusion:
Pyrocarbon arthroplasty provides an excellent option for joint preservation in cases of acute and post traumatic arthritis of the MCP and CMC joint. Joint
replacement provided pain relief while maintaining adequate ROM for post-operative activities. All patients returned to previous employment. Further study is
required to assess long-term outcome.
Biomechanical Comparison of Three Fixation Techniques of Four Corner Arthrodesis: K wires vs Circular plate (Spider Plate) vs
Locked Circular plate (Xpode Plate)
Alexander Y. Shin, MD1; Jirachart Kraisarin, MD2; Lawrence J. Berglund, BS1; David G. Dennison1; Kai-Nan An, PhD1; (1)Mayo Clinic, (2)Chang Mai
University
Introduction:
Four-corner arthrodesis is a common technique for salvage of degenerative wrist problems as well as carpal instability. Advocates of plate fixation state that
rigid fixation allows early motion, which improves outcome of surgery. Despite this claim, there have been no comparative studies the effect of early motion on
fixation type. The purpose of this study is to compare biomechanical profile of Kwires versus locked and unlocked dorsal circular plate in four-corner arthrodesis in physiologic condition mimicking early active range of motion.
Materials and Methods:
6 paired(12wrists) of fresh frozen cadaveric wrists underwent scaphoidectomy and four corner arthrodesis using K-wires (0.045” x 4) , unlocked stainless steel dorsal circular plates(Spider plate, Kinetikos Medical Inc.) or locked polyethlyethlyketone circular plate (Xpode, Trimed Inc.) An electromagnetic motion sensor was placed in the capitate
and lunate. The specimens were placed in a cyclical flexion-extension wrist joint simulator. Repetitive cyclic wrist flexion and extension was applied using both displacement
and force control. Hardware failure or motion > 2 mm was considered a failure of fixation.
Results:
The biomechanical profiles for 5000 cycles and the initial 100 cycles are shown below(Figure). 67% in the K wire group catastrophically failed, and 67% of
the Spider plate group failed. There were no failures of the Xpode plate fixation group. Mode of failure in K-wire group were including pin breakage, bending, and loosening. For the spider group failure mechanism involved loosening screws.
Discussion:
This study determined the immediate stability of each fixation technique for cyclical loading mimicking early motion. Spider plate provide more rigid fixation
in flexion and abruptly increase motion when more than 35 degree wrist extension occur. Xpode plate provided more stability in extension and was able to
withstand cyclical loading in this experiment, and could tolerate simulated early range of motion without failure.
61
Outcome assesment of arthroscopic interpositional arthroplasty of the trapeziometacarpal joint
Institution where the work was prepared: Brown Hand Center, Phoenix, AZ, USA
Michael Fitzmaurice, MD; P. Stephen Mahoney, MD; Michael Brown, MD; Brown Hand Center
Osteoarthritis of the trapeziometacarpal joint is a common cause of pain in the upper extremity. Small joint arthroscopy allows performance of partial trapeziectomy with interposition arthroplasty without the morbidity of an open procedure. We describe the preliminary results of an outcome assessment of interposition
arthroplasty with the artelon implant utilizing the DASH and Nelson scores. The DASH score is a general outcome assessment of function and symptoms in the
upper extremity, however, the Nelson score is a new outcome tool designed specifically for trapeziometacarpal arthritis. The DASH is scored from 0-100 with
the higher number indicating greater disability. The Nelson is also scored from 0-100; however the lower number indicated greater disability. 21 procedures
on 19 patients (2 bilateral) have been performed. Evaluation was performed pre-operatively and at 13 weeks post-operatively. Nearly all patients had full
range of motion and were able to touch the small finger to the 5th metacarpal head. Patients who were not retired were able to return to normal work activities. The average DASH score pre and post-operatively was 46 and 22. The average Nelson score pre and post-operatively was 49 and 75. There was a significant improvement in both scores, however, the Nelson score is a shorter survey, easier for patients to complete and appears to be more specific to
trapeziometacarpal arthritis. The outcome assessments for the arthroscopic partial trapeziectomy with arthroplasty utilizing the artelon implant demonstrate a
significant improvement in both function and symptoms without the morbidity associated with open techniques.
Short-Term Outcomes of Trapeziometacarpal Artelon Implant Compared with Abductor Pollicis
Longus Tendon Interposition Arthroplasty - A Case-Control Study
Institution where the work was prepared: Department of Orthopedics, Hässleholm Hospital, Hässleholm, Sweden
Isam Atroshi, MD, PhD; Ingrid Isaxon, PT; Magnus Flondell, MD; Maria Jörheim, MD; Peter Kalén, MD, PhD; Hässleholm Hospital
Background:
Several implants have recently been introduced for the treatment of trapeziometacarpal (TMC) osteoarthritis. The Artelon implant is a biodegradable T-shaped
device designed to be placed in the TMC joint following minimal trapezial resection to provide joint reconstruction and stabilization. This study aimed to compare short-term efficacy of the Artelon implant with that of trapeziectomy and Abductor Pollicis Longus (APL) tendon suspension interposition arthroplasty.
Methods:
A case-control study was designed to include at least 3 controls for each case. The inclusion criteria were primary TMC osteoarthritis that failed nonoperative
treatment, surgery with the Artelon implant or trapeziectomy and APL tendon suspension interposition arthroplasty, and postoperative follow-up time of at least
6 months. The Artelon group comprised 13 consecutive patients (10 women), mean age 54 (range 44-75) years. The APL group comprised 40 patients (33
women), mean age 58 (43-76) years, randomly selected with computer among 88 consecutive eligible patients. The mean follow-up time for the Artelon group
was 13 (SD 4) months and for the APL group 12 (SD 3) months. All patients completed the QuickDASH questionnaire and a scale measuring thumb pain and
related activity limitation, both scored from 0 (best) to 100. Satisfaction with the results of surgery was recorded. The majority attended physical examination
performed by a therapist who was blinded to the surgical procedure.
Results:
No statistically significant differences between the groups were found but a tendency for better results after APL arthroplasty. The median QuickDASH score for
the Artelon group was 25 and for the APL group 20 and the median pain score was 38 and 28, respectively. In the Artelon group 8 patients (61.5%) were satisfied and 5 (38.5%) were neutral or dissatisfied compared with 32 (76%) and 7 (18%), respectively, in the APL group. The mean grip strength as a percentage
of the contralateral hand was 82% in the Artelon group and 95% in the APL group and the mean pinch strength was 61% in the Artelon and 86% in the APL
group. No statistically significant differences were found between the groups with regard to thumb palmar or radial abduction. One patient in the Artelon group
underwent revision to APL arthroplasty.
Conclusions:
The short-term outcomes of Artelon implant arthroplasty are at best similar to those of APL tendon suspension interposition arthroplasty. Considering the higher cost of the Artelon implant, these results may not justify its use in the treatment of TMC osteoarthritis.
The Effect on Wrist Flexion Strength of Thumb Carmpometacarpal Joint Arthroplasty Using the Entire Flexor Carpi Radialis Tendon
Institution where the work was prepared: Curtis National Hand Center, Baltimore, MD, USA
Rebecca J. Saunders, PT/CHT; Michael S. Murphy, MD; Curtis National Hand Center at the Union Memorial Hospital
Introduction:
Thumb carpometacarpal joint arthroplasty with ligament reconstruction and tendon interposition is a well established procedure for painful arthrosis of the
thumb carpometacarpal joint. Many surgeons utilize the entire flexor carpi radialis (FCR) tendon for ligament reconstruction, while some prefer preserving part
of the tendon’s normal insertion onto the second metacarpal base.
Purpose:
To determine if harvesting the full FCR tendon effects postoperative wrist flexion strength.
Methods:
A prospective study of 17 patients who underwent thumb carpometacarpal joint arthroplasty with ligament reconstruction and tendon interposition was performed. All patients underwent isometric testing of wrist strength and motion preoperatively, at three months postop, and at six months postop utilizing the
Dexter Hand Therapy System automated testing device for strength testing. Testing and ROM measurements were performed by one CHT.
Results:
The data was analyzed using paired t tests. There was no statistically significant difference in the wrist flexion strength between preoperative and final postoperative values at 6 months. Average wrist flexion strength, measured in inch-pounds, was 36.7 preoperatively and 37.8 at six months postop (P=0.71). There
was also no significant difference in final wrist flexion range of motion. Average wrist flexion preop was 78.9 degrees and at 6 months postop was 77.0
(p=0.51)
Conclusion:
Utilizing the entire FCR tendon for thumb CMC arthroplasty with ligament reconstruction and tendon interposition does not adversely effect eventual wrist flexion strength or the range of wrist flexion.
62
Long-term Follow-up of Surface Replacement Arthroplasty of the PIP Joint
Peter M. Murray, MD; William P Cooney; Ronald L Linscheid; The Mayo Clinic
Introduction:
We propose that surface replacement arthroplasty is a durable alternative for the treatment for osteoarthritis (OA) and rheumatoid arthritis (RA) of the proximal interphalangeal (PIP) joint of the finger. The purpose of this study is to examine the long-term outcome of a surface replacement PIP joint prosthesis with a
CrCo proximal component and an ultrahigh-molecular-weight polyethylene distal component.
Methods:
51 prostheses were used in 36 patients (mean age, 58 years) over 32 years. There were 33 fingers with degenerative arthritis, 9 with post-traumatic osteoarthritis, and 9 with rheumatoid arthritis. The mean follow-up was 10.7 years (range, 2.6-31.8 years). 44 patients had a dorsal approach, 5 a volar approach and
2 had a lateral approach. 35 patients had cement and 16 had a press fit technique. At follow-up patients were evaluated by physical examination, radiography, DASH, and SF36 assessments.
Results:
Average total arc of motion at follow-up was 42 degrees compared to 43.7 degrees pre-operative. 45 of 51 joints were in service at follow-up examination.
The average post-operative visual analog pain score was 8/100. 26 of 36 patients had reported pain pre-operative with 6 being severe. The average followup DASH score was 46.5, many patients had multiple disabilities. There were 28 complications in 10 patients including 4 fusions and 2 amputations.
Complications included extensor and flexor tenodesis, heterotopic bone formation, boutonnière deformity and swan-neck deformity. Additional radiographic
complications of polyethylene wear and asymptomatic loosening occurred in 4 and 3 patients respectively. Infection did not occur.
Discussion:
At long-term follow up, PIP arc of motion was less but similar to pre-operative motion. 90% of the prostheses were still in service at follow-up and pain relief
was excellent. Infection did not occur. We conclude that PIP joint surface replacement arthroplasty is a durable and pain relieving alternative for the arthritic
PIP joint of the finger.
Flexor Tendon Tissue Engineering: Bioreactor Cyclic Strain Increases Construct Strength
Institution where the work was prepared: Stanford University and Palo Alto VA, Palo Alto, CA, USA
Sepideh Saber, BS1; Andrew Y. Zhang, MD1; Sae H. Ki, MD1; Derek Lindsey, MS2; Hung M. Pham, BS1; James Chang, MD/FACS3; (1)Stanford
University, (2)VA Palo Alto Health Care System, (3)Stanford University Medical Center
Purpose:
Mutilating injuries of the hand and upper extremity result in tendon losses too great to be replaced by autologous grafts. Our goal is to use tissue engineering
techniques to produce additional tendon material. In this study, we used a custom bioreactor to apply cyclic mechanical loading onto tissue engineered tendon
constructs to study ultimate tensile stress, elastic modulus, construct architecture, and cell orientation.
Methods:
A custom LigaGen tissue bioreactor providing uniaxial tendon strain was used for this study. Tendon constructs were subjected to a stretch force of 1.25N over
a 5 day course. Constructs used were acellularized tendons reseeded with tenocytes or left unseeded. Actual tendon strain was measured linearly by comparing resting tendon length to tendon length under applied tension. Ultimate tensile stress and elastic modulus of the tendon constructs were compared after different cycle parameters (1cycle/min vs. 2cycles/min in alternating 1 hour periods of loading and rest) using a materials testing system (MTS 858, MTS Inc).
Histologic appearances were examined for tendon architecture with specific emphasis on collagen organization and cell orientation. Finally, pairwise comparison of means across groups was assessed using the two-tailed unpaired Student T-test with the significance level set at p < 0.05.
Results:
Seeded tendon constructs that were exposed to a 1 cycle/min load were found to have a significantly increased ultimate tensile stress and elastic modulus (UTS
= 84.73N; ë = 1054.77MPa) compared to non-loaded controls (UTS = 38.90N, p = 0.002; ë = 699.98MPa, p = 0.03). Seeded tendon constructs exposed
a 2 cycle/min load also had a significant yet less remarkable increase (UTS = 73.95N; ë = 1045.21MPa) compared to non-loaded controls (UTS = 38.90N,
p = 0.01; ë = 699.98MPa, p = 0.02). Histologically, stressed tendons showed better alignment of collagen fibrils. Cyclic strain further caused the cells and their
actin cytoskeleton to reorient parallel to the direction of strain. This alignment was in stark contrast to the random cell orientation of unstressed constructs.
Relevance:
This study shows that cyclic loading of tendon constructs increases the strength of seeded constructs and changes the constructs’ collagen architecture and cell orientation. The use of the bioreactor may therefore accelerate the in vitro production of strong, non-immunogenic tendon material that can potentially be used clinically to reconstruct significant tendon losses. The ultimate goal of this project is to produce tissue engineered tendon for clinical use in hand and upper extremity reconstruction.
Barbed Suture Tenorrhaphy - An Ex-Vivo Biomechanical Analysis
Institution where the work was prepared: Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD, USA
Pranay M. Parikh, MD1; James Patrick Higgins, MD2; Steven Paul Davison, MD, DDS1; (1)Georgetown University, (2)Union Memorial Hospital
Purpose:
Use of a barbed suture for flexor tenorrhaphy could permit knotless repair with tendon barb adherence along the suture’s entire length. The purpose of this
study is to evaluate the tensile strength of a novel technique for flexor tendon repair employing barbed suture.
Methods:
Forty cadaveric FDP tendons were lacerated in Zone II and randomized to a novel barbed 2-0 polypropylene repair in a knotless 3-core or 6-core configuration, or to a traditional 4-core cruciate repair with either 4-0 polypropylene, 4-0 braided polyester, or 4-0 fiberwire. For each repair, we recorded the crosssectional area at the repair site before and after tenorrhaphy. Tendons were linearly distracted to failure, and load at failure and mode of failure recorded.
Results:
The mean cross-sectional area ratio of 4 core cruciate control repairs was 1.5 +/- 0.3, whereas those of 3-core and 6-core barbed repairs were 1.2 +/- 0.2
(p = 0.009) and 1.2 +/- 0.1 (p = 0.005), respectively. The mean load to failure of control repairs was 29 +/- 7N, whereas those of 3-core and 6-core barbed
repairs were 36 +/- 7N (p = 0.32) and 88 +/- 4N (p < 0.001), respectively. Cruciate repairs failed by knot rupture or pullout in 24/24 tendons whereas
barbed repairs failed by suture breakage in 13/14 repairs (p < 0.001).
Conclusions:
In an ex-vivo model of flexor tendon repair, a 3-core barbed suture technique achieved tensile strength comparable to that of traditional 4-core cruciate repairs,
while demonstrating significantly less repair site bunching. A 6-core barbed suture technique demonstrated markedly increased tensile strength compared to
4- core cruciate controls, as well as significantly less repair site bunching. Our data suggest that barbed suture repair may offer several advantages in flexor
tenorrhaphy, and that further in-vivo testing is warranted.
63
Brunelli Pull-OutTechnique in Flexor Tendons Repair in Zones II and III: A Study on 65 Cases
Institution where the work was prepared: University of Medicine Cluj, Spitalul Clinic de Recuperare, Cluj-Napoca, Romania
Alexandru Georgescu, Prof, MD, PhD; Irina Capota, MD; Filip Ardelean, MD; Ileana Matei, MD; UMF Iuliu Hatieganu
Background and Aims
Reconstructing the continuity of long fingers flexor tendons in zones II and III still raises problems from operative point of view. One of the surgical methods
with great success rate for zone II lesions is the pull-over technique described by Brunelli. In this paper we will present the modifications proposed by us for this
technique, as well as the indication’s expansion for lesions in zone III.
Material and Method
The study refers to 65 cases involving flexor tendon lesions in zone II and III, operated in our service since the year 2000 until now. From these, 58 were zone
II lesions and 7 zone III lesions. Lacking the very long and highly curved needles used by Brunelli, we modified the initial technique by starting from the proximal towards the distal area and used 2 straight needles continuous threads. In addition and especially for the zone III lesions, we incised the digital skin until
near the insertion area of flexor digitorum profundus and the suture thread was passed through the tendon in one or more steps to reach the distal end of the
tendon. In 42 cases we used non-absorbable sutures that were removed after 21 days, and in 23 cases absorbable sutures, that were only cut after 21 days.
In 57 cases the surgical procedure took place under regional anesthesia that allowed the reinforcement of patient’s psychological motivation, seeing the favorable results during surgery. The recovery started from the first post-operative day with passive fingers mobilization, and 48 hours after the surgery we initiated the active against-resistance mobilization.
Results
The patients were followed for 3-24 months after the surgery. We obtained a complete flexion in 32 patients; in 7 patients we had a flexion deficit of 5-10
degrees, in 19 patients we had a 10-20 degrees flexion deficit and in 7 cases we had a 20-30 degrees flexion deficit (all of them having zone III lesions). All
the patients were able to resume social life and work in the same place after maximum 45 days. We had no rupture cases and tenolysis was necessary in
only 5 cases (patients with complex traumas).
In conclusion, we consider that the Brunelli’s technique is a very good method for zone II lesions and that the modifications proposed by us allow a broadening of its indication’s field.
Flexor Tendon Tissue Engineering: the Biomechanical Analysis of Explanted Acellularized Tendon Constructs
Institution where the work was prepared: Stanford Hospital and Clinics and the VA Palo Alto Healthy Care , Palo Alto, CA, USA
Andrew Y. Zhang, MD1; Sae H. Ki, MD1; Sepideh Saber, BS1; Derek Lindsey2; Hung M. Pham, BS1; James Chang, MD3; (1)Stanford University, (2)VA
Palo Alto Health Care System, (3)Stanford University Medical Center
Purpose:
The demand for tendon grafts may exceed supply in mutilating hand injuries. Our tissue engineering model uses the acellularized rabbit forepaw zone II flexor tendon
as the scaffold. Cultured tenocytes and adipoderived stem cells (ASCs) are seeded onto acellularized tendon to create novel tendon constructs. Previous studies have
established that these constructs are viable in vitro, and that the constructs along with acellularized scaffold maintain comparable tensile strength to fresh tendons in vitro.
The purpose of this study is to investigate the in vivo integrity of our scaffold and tendon constructs.
Methods:
The experimental cohort contains three groups including 1) acellularized tendon scaffolds, 2) constructs seeded with cultured tenocytes, 3) constructs seeded
with ASCs. These constructs were grafted to span a 2 cm gap in rabbit zone II 3rd digit FDP tendons. Our controls included autologus tendon graft over the
same area in the adjacent 4th digit and intact fresh tendon in the 2nd digit. Macroscopic and histological appearances along with mechanical testing for ultimate tensile stress (UTS) were determined at 2 and 4 weeks time points. Statistical analysis was performed using the paired two-tailed student t test.
Results & Conclusions:
All cohort groups have macroscopic appearances indistinguishable from autologus graft and fresh tendon at all time points. There did not appear to be significant adhesion formation between the grafts and the tendon sheath. Histologically, collagen architecture was preserved in all experiments groups. Minimal cell
penetration into the collagen architecture was noted, however it appears that there was more cell penetration as time elapsed. The UTS was not statistically different between our three experimental cohorts and controls. At 2 weeks time point, the average UTS for intact tendon was 60(N/mm2) compare to 52(N/mm2)
for autologus graft (n=12; P=0.2), 61.2(N/mm2) for acellularized tendon (n=3, P=0.46), 46(N/mm2) for Tenocyte seeded constructs (n=4, P=0.55), and
67(N/mm2) for ASC seeded constructs (n=7; P=0.12). At 4 weeks, the average UTS for intact tendon was 53(N/mm2) compare to 42(N/mm2) for autologus
graft (n=7; P=0.13), 46(N/mm2) for acellularized tendon (n=3; P=0.5), 41(N/mm2) for Tenocyte seeded constructs (n=3; P=0.29), and 42(N/mm2) for ASC
seeded constructs (n=3; P=0.3).
Relevance:
Our study suggests that tissue engineered grafts remain viable in the short-term in vivo. Surprisingly, acellularized tendon alone retained strength and may be
a suitable substitute for autologus grafting in the short term. Further work will include longer follow up and analysis of repair strength and construct gliding
characteristic.
64
Biomechanical Comparison of Lasso Tendon Repair to Pulvertaft Weave and Side-to-Side Repairs
Institution where the work was prepared: University of Texas Southwestern Medical Center, Dallas, TX, USA
Sean Bidic; Anubodh Varshney, BS; Harry Orenstein; University of Texas Southwestern Medical Center
Introduction:
Pulvertaft weaves, although reliable, require substantial tendon length for overlap. Side-to-side tendon repair are less reliable. A new technique for joining tendons, the lasso repair, has been developed. The hypothesis is that the lasso has similar biomechanical strength as the Pulvertaft weave, requires less tendon,
and is simpler to perform.
Methods:
Lasso repair involves making an axial stab incision 1.5 cm from the end of the passive tendon that allows the active tendon to be tightly weaved using a hemostat. A second longitudinal incision is made in the active tendon such that the active tendon can be weaved through itself. Horizontal mattress sutures are placed
at both weave points; an additional suture is placed in between the incisions. Pulvertaft weave repairs had three weaves and sutures and side-to-side repairs had
three sutures embedded in the 2.5 cm overlap. Repairs were conducted using porcine trotter flexor tendons obtained at animal sacrifice. Lasso and Pulvertaft
weave repairs were standardized with the first incision 1.5 cm from the end of one tendon. Side-to-side repairs were standardized to a 2.5 cm overlap. 4-0
Mersilene suture with 5 knots per suture was used. Ten repairs of each type were performed. Tendon length used in each repair and width of the repair, and time
to complete the repair were assessed. Repair failure for each repair was measured using a tensile testing machine with a 5 kN load cell was used to test repairs
to failure at a crosshead speed of 20 mm/minute. Load and extension plots and maximum load were digitally recorded using data acquisition software.
Results:
The mean maximum load in the side-to-side, Pulvertaft weave, and lasso repair specimens was 88.58N, 159.67N, and 155.78N respectively. Maximum load is
found to be the same between lasso and Pulvertaft weave repair based on the Student’s t-test (p<0.05). Lasso repair used 7.1mm less tendon than the Pulvertaft weave
and took less than half of the time to complete. Lasso repair is slightly thicker at its widest point than the Pulvertaft weave, but the thickness is concentrated to a small
area, while in Pulvertaft weave repairs the thickness is spread out throughout the specimen.
Conclusions:
Our study supports the hypothesis that lasso tendon repair is as strong as the Pulvertaft weave, takes less time to perform, and requires less tendon. Side-toside repair is shown to be an inferior technique due to its characteristically low maximum load.
Flexor Tendon Repair using Modified Lim and Tsai Six Strand Suture Technique
Institution where the work was prepared: Department Of Surgery, Singapore General Hospital, Singapore, Singapore
Jayan Man Shrestha, MS, (General, Su; Shian Chao Tay, MD, MS; Singapore General Hospital
Introduction:
Flexor tendon repair with 6 strand suture technique has resulted in improved strength and increased resistance to gapping. We used a modification of Lim and
Tsai’s technique for flexor tendon repair and assessed the clinical outcome.
Methods:
A retrospective review of all complete flexor digitorum profundus (FDP) and flexor pollicis longus (FPL) tendon injuries in zones 1,2 and 3, with or without flexor digitorum superficialis (FDS) tendon injuries, from May 2002 to May 2006 was conducted. Thirty-one patients with 38 fingers and thumbs were found.
Functional outcome was assessed using Strickland and Glosovac’s criteria for the finger, and White’s method for the thumb.
Results:
Out of a total of 38 digits, 22 were rated as excellent ( 58%), 9 good (24%), 7 fair (18%) ad 0 poor (0%). Twenty-five of these digits were injured in zone 2
and, 13 digits of these digits were rates as excellent (52%), 6 good (24%), 6 fair (24%) and 0 poor (0%). The rate of flexor tendon rupture was 2.6%.
Conclusion:
The modified Lim and Tsai technique for flexor tendon repair is a useful 6-strand technique for flexor tendon repair with a satisfactory outcome rate.
65
Biomechanical Comparison of FiberLoop versus Looped Supramid Extra versus Ethibond
Suture in Zone II Flexor Tendon Repair Using a Cyclic Protocol
Joy V. Sharma, MD, MS; Ryan Milks, BSE; Kathleen A. Derwin, PhD; Peter J. Evans, MD, PhD; Jeffery N. Lawton, MD; The Cleveland Clinic
The purpose of this study was to investigate differences in gap formation and failure load between FiberLoop, looped Supramid Extra (LSME), and Ethibond
suture in Zone II flexor tendon repairs. In addition, the inherent properties of the sutures were tested in a simulated tendon construct.
Two sets of ten paired human cadaveric flexor digitorum profundus tendons were used. The tendons were transected in zone II, and randomly repaired with
either 4-0 FiberLoop or 4-0 LSME in the first set of ten paired tendons. The second set of ten were randomly repaired with 4-0 Ethibond or 4-0 FiberLoop. All
repairs where performed using an eight-strand cruciate repair technique followed by a running epitendinous 6-0 prolene suture. The repaired tendons were
cycled 8000 times between 2N and 25N and then pulled to failure. Suture markers were placed on both sides of the repair site to analyze gap formation. In
the second part of the study, an eight-strand cruciate repair was performed using a custom fixture simulating a tendon construct. Failure load, method of failure, and knot volumes were recorded and statistically analyzed for the aforementioned suture products.
In the first part of the study, no significant differences were found in gap formation between suture types at 8000 cycles. All mean gaps were less than 2mm.
FiberLoop repairs failed at significantly (p=0.002) higher loads (72.9 ± 6.6 N) when compared to LSME (64.3 ± 8.8 N). However, no significant difference in
failure loads was found in the paired flexor tendons comparing FiberLoop and Ethibond. All repairs failed at the tendon suture interface. In the second part of
the study, FiberLoop failed by knot slippage at low loads when four throws per knot were used. When six throws per knot were used FiberLoop (235 ± 15.6
N) was significantly stronger than LSME (114.5 ± 6.3 N) and Ethibond (123.9 ± 12.6 N) and majority of repairs failed by suture breakage.
Our data suggests that all three suture products were able to withstand cyclical loading with less than 2mm gap formation using an eight-strand cruciate repair
technique. The second part of the study suggests that FiberLoop is inherently stronger than LSME and Ethibond but the increased strength is realized only when
an increased number of throws is used to secure the knot. In the clinical setting, suture breakage may be irrelevant as all repair failures occurred at the suture
tendon interface regardless of suture product.
Indications and Clinical Experience Using Adhesion Barrier Wrapping
Institution where the work was prepared: Miami Hand Center, Miami, FL, USA
Alejandro Badia, MD, FACS; Badia Hand to Shoulder Center
The development of postoperative adhesions has long caused clinical problems for hand surgeons in a variety of scenarios. Acute repairs of either tendons or
nerves has often been associated with the development of exuberant scar tissue postoperatively that interferes with function. It has been a long sought after goal
to try to minimize adhesions using a variety of techniques in order to improve clinical outcome after these types of surgical interventions. Recurrance of adhesions is also a common problem after either tenolysis or neurolysis. The use of a bioresorbable polylactide sheet to minimize adhesions to a protected viscera
has demonstrated good clinical benefit in general surgery and gynecologic surgery applications. It is comprised of polylactic acid (PLA) which has a long clinical track record of having minimal tissue reaction with no known side effects. These same benefits have only recently been introduced in the musculoskeletal
arena. Clinical indications will be outlined and a series of case examples presented in order to illustrate this concept as applied to hand surgery. Follow-up on
these patients has demonstrated no adverse foreign body or inflammatory response, and the clinical goals have been achieved in all cases: namely that of minimizing adhesions as demonstrated by physical exam at the application site. While this physical barrier does not solve the elusive goal of reducing adhesions
in zone II flexor repairs due to its mechanical nature, it seems promising for minimizing post-op adhesions in such critical areas as the dorsum of the hand,
forearm flexor/extensor tendon applications, and a wide variety of peripheral nerve applications. A future prospective randomized study assessing one specific clinical scenario will shed further light on its efficacy.
66
AAHS Concurrent Scientific Paper Session A-2
Intramedullary Fixation of Displaced Distal Radius Fractures
Asif M. Ilyas, MD; Joseph J. Thoder, MD; Temple University Hospital
Purpose:
Multiple treatment options exist for operative fixation of distal radius fractures. Recently, there has been increased interest in intramedullary fixation. We treated 10 displaced and unstable distal radius fractures with an intramedullary nail over a one year period. We present our results with an average follow-up of
21 months (minimum 12 months).
Methods:
The implant use was limited to extra-articular and simple intra-articular distal radius fractures that displayed instability or persistent malreduction after attempted closed reduction and splinting. The patients were followed at set intervals for a minimum of 12 months.
Results:
At an average follow-up of 21 months, the average volar tilt was 3.8° dorsally angulated, radial inclination was 22.9°, radial height was 12.1mm, and ulnar variance was -0.6mm. All cases maintained reduction of the fracture between immediate post-operative and final radiographs except for two cases that incurred a loss
of volar tilt by 15° and 20°, respectively. Range of motion included wrist flexion of 67°, wrist extension of 71°, supination of 82°, pronation of 85°, radial deviation
of 23°, and ulnar deviation of 38°. Grip strength of the operative limb relative to the uninjured limb was 91%. According to the DASH form there was 8 excellent,
1 good, and 1 poor result. The average DASH score was 8.12 (range, 0-57). There were two cases of transient superficial radial sensory neuritis and one case of
late DRUJ arthrosis from implant penetration of the joint.
Conclusion:
Our report finds that the use of the intramedullary nail in the treatment of displaced distal radius fractures is promising but not without complications. We found
good overall maintenance of reduction except in two cases without any long-term soft tissue problems in any cases. The indication for its use should be limited
to extra-articular and simple intra-articular distal radius fractures.
Comparison of AO Type B and Type C Volar Shearing Fractures of the Distal Radius
Institution where the work was prepared: Massachusetts General Hospital, Boston, MA, Tuvalu
Jesse Jupiter1; J. Sebastiaan Souer2; David Ring1; (1)Massachusetts General Hospital, (2)Mass General Hospital / Harvard Medical School
Purpose:
Fractures of the volar articular margin of the distal radius with volar radiocarpal subluxation (volar shearing fractures) can be accompanied by fracture of the
dorsal metaphyseal cortex. We hypothesized that, among volar shearing fractures, injuries with a dorsal cortical break (AO/OTA Type C fracture) are more
common than isolated volar marginal articular fractures (partial articular or Type B fractures). We also compared wrist function and perceived disability after
both types of fractures.
Methods:
In a prospective cohort study of plate and screw fixation of the distal radius, 58 patients with a volar marginal shearing fracture of the distal radius and volar radiocarpal subluxation (volar Barton’s fracture) were followed for at least one year. Thirty-eight patients that also had a dorsal metaphyseal cortical fracture (Type C fracture) were compared with 20 patients with a true (Type B) fractures in terms of demographics, injury circumstances, and outcomes according to motion, grip strength,
pain, Gartland/Werley Score, DASH and SF-36 scores at 6, 12, and 24 months follow-up.
Results:
There were no differences in baseline characteristics between Type B and C fractures. Patients with Type C fractures had significantly less motion forearm rotation (163 vs. 174 degrees; p=0.05), grip strength (72% vs. 85% of opposite arm; p=0.03), and significantly more pain (2.2 vs. 0.6; p=0.01) than patients with
Type B fractures at the early (6 month) follow-up, but not at later (12 and 24 month follow-ups). There were no significant differences in Gartland and Werley,
DASH, or SF-36 scores at any time point.
Conclusions:
Type C volar shearing fractures take longer to recover, but ultimately do as well as true Type B volar shearing fractures.
Significance:
Volar shearing fractures are usually complete articular, Type C fractures
67
Distal Radius Fractures Treated with Multiplanar Cross Pin Fixation and a Low Profile Non-Bridging External Fixator; the CPX System
Institution where the work was prepared: Ather Mirza, MD, Smithtown, NY, USA
Ather Mirza, MD; Ather Mirza, MD
Purpose:
To present the findings of distal radius fractures (DRF) treated with the CPX System.
Methods:
Forty-nine patients with 52 unstable DRF (40 intra-, 12 extra-articular) were treated with the CPX System. Mean age 54 years (range 17-87 y). Radiological
measurements, grip and pinch strength, active wrist range of motion (AROM), and outcome instruments: The Patient-Rated Wrist Hand Evaluation (PRWHE)
and the Disabilities of the Arm, Shoulder and Hand (DASH) was used to determined patient’s outcome.
Results:
Postoperatively, a removable orthosis was applied, mean 6 days (range 2-10 d) and formal wrist rehabilitation began, mean of 8 days (range 2-16 d). There
were no pin tract infections, non-unions, tendon injuries or angular collapses. Radiographic parameters were not fully restored in four patients. Two patients
had an increase in ulnar variance. K-wires and external fixation was removed, mean of 46 days (range, 39-61 d). At final follow-up (mean 14 ± 10 months)
grip and lateral pinch strength recovered 87% and 94% respectively; mean wrist AROM increased to a minimum of 83% of the non-injured side; mean DASH
and PRWHE scores were 12.16 ±14.62 and, 13.8 ±14.8 respectively. One patient developed complex regional pain syndrome which revolved and one patient
had mild transient superficial radial nerve sensitivity without functional compromise. All returned to their prior employment and/or activities.
Conclusion:
The CPX System combines multiplanar internal cross pin fixation with a low profile external fixator, providing maintenance of fracture reduction while allowing
rehabilitation of the wrist, and resumption of usual activities.
Treatment of Distal Radius Fractures Using a Radial Stabilization Locking Plate
Institution where the work was prepared: Texas Tech University Health Science Center, El Paso, TX, USA
Miguel Pirela-Cruz, MD; Texas Tech Medical Center; David Esquivel, ORT; Texas Tech University Health Science Center
Introduction
Volar plating of distal radius fractures (DRF’s) is currently the treatment of choice for addressing unstable fractures of the distal radius. However, there some fractures that require operative intervention but with a less invasive approach. DRF’s can now be treated with a radial locking plate that provides adequate stabilization of the fracture and allows for early range of motion (ROM).
Material and Methods
A retrospective review of 36 DRF’s was performed. One surgeon in one institution using a newly developed anatomic distal radius plate carried out the surgeries on Type A (extra-articular) and some Type B (partial articular). Supplementary fixation such as a single 0.045 k-wire was required rarely. Range of motion
exercises was started one week post-operatively.
Results
All fractures were healed at 6 months post-operatively. A few patients experienced transient paraesthesias in the distribution of the superficial branch of the radial
nerve. By 6 months however, the paraesthesias were resolved. Range of motion, D.A.S.H. scores and SF-36 will be presented.
Conclusion
0.R.I.F. using a radial stabilization locking plate provides a simple alternative to traditional volar plating in selective fractures. This approach reduces the surgical dissection and facilitates post-operative recovery..
A Prospective Randomized Clinical Trial of Unstable Distal Radius Fractures treated with External Fixation, Radial Column Plating, or Volar Plating
Institution where the work was prepared: New York Orthopaedic Hospital, Columbia University Medical Ctr, New York City, NY, USA
David H. Wei, MSc1; Noah M. Raizman, MD2; Clement J. Bottino, MD1; Charles M. Jobin, MD1; Robert J. Strauch, MD1; Melvin P. Rosenwasser, MD1; (1)New
York Orthopaedic Hospital, Columbia University Medical Center, (2)George Washington University School of Medicine
Background:
Optimal surgical management of unstable distal radius fractures is controversial. External fixation and locked volar plating demonstrate excellent clinical results, but
evidence from rigorous comparative trials is rare. Additionally, locked radial column plating as an independent method of fixation has not been examined. We compare functional outcomes following external fixation, locked volar plating, and locked radial column plating.
Methods:
Forty-six patients with single limb injuries were randomized as follows: twenty-two to external fixation, twelve to locked volar plating, and twelve to locked radial column plating. Fractures included OTA types A3 and C1-C3. At two, six, twelve, twenty-four, and fifty-two weeks after surgery, patients completed the
Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. Grip and lateral pinch strength, range of motion (ROM), and radiographic parameters were
also evaluated.
Results:
At six weeks, volar plating demonstrated a significantly better mean DASH score compared to external fixation (p=0.037), but was not significantly different from
radial column plating (p=0.33). At three months, volar plating demonstrated the best DASH score, significantly better than external fixation (p=0.028) and radial column plating (p=0.027). By six months and one year, all three groups reached DASH scores comparable to the normal population. External fixation showed
significantly better grip strength compared to radial column plating (p=0.042) at six months, but at one year no significant differences were observed. Volar plating showed significantly better lateral pinch strength compared to radial column plating at three months (p=0.042) and one year (p=0.036), but no significant
differences were found when compared to external fixation. ROM did not significantly differ between groups at any time beginning twelve weeks after surgery.
Radial column plating maintained the best radial inclination and radial length at one year, significantly better than both external fixation and volar plating (all
p<0.05).
Conclusions:
Early rehabilitation of locked volar plating predictably leads to better patient reported outcomes in the first three months after fixation. However, by one year
all three techniques provide excellent outcomes despite minimal differences in strength, motion, and radiographic alignment.
68
Minimally Invasive Osteosynthesis (MIO) for Asian Osteoporotic Distal Radius Fractures
with Small Intramedullary Nail
Naoya Takada; Komaki City Hospital
Purpose:
Distal radius fracture is one of common injuries in Asian elderly population. Since 2006 we have used MIO technique with a small intramedullary nail for osteoporotic
distal radius fractures. The purpose of this study is to evaluate the clinical outcome of 20 osteoporotic distal radius fractures treated with this method retrospectively.
Methods:
Twenty female patients who had sustained distal radius fracture were treated with MIO technique using small intramedullary nail. Their average age at the time
of surgery was 67 (range 55-85). According to the AO/OTA classification system, 9 patients were type 23-A2, 3 type 23-A3, 6 type 23-C1, 2 type 23-C2.
Two small skin incisions (1.5-2 cm) were used for this procedure. The small intramedullary nail was inserted from a cortical window between the 1st and 2nd
dorsal extensor compartments. Three distal buttress screws were inserted into distal fragment and 2 locking screws were inserted into proximal fragment. No
patient required post operative immobilization. The average follow-up period was 8.2 months (range 3-18). The range of motion of the wrist, Green and
O’Brien score, Quick DASH score and radiographic outcomes were assessed at the latest follow-up and post operative complications were evaluated.
Results:
The average range of flexion and extension were 61 (range 50-90) and 62 (range 45-90) degrees. The average Green and O’Brien score was 88 (range 75100) points. The average Quick DASH score was 3.7 (range 0-13.6) points. Palmar tilt, ulnar variance, radial inclination and radial height at the final followup X-ray were 10 degrees, 0.5 mm, 20 degrees and 9 mm respectively. Loss of reduction, implant failure, deep infection and tendon or nerve problems were
not found postoperatively.
Conclusion and Significance:
No postoperative complications were observed and the clinical outcome was good in this study. This angular stable implant maintained reduction position even
in osteoporotic bone. Small skin incisions are advantageous to cosmetic effect. Using this MIO technique, pain and swelling can be little and patients can quickly return to activities of daily living. The small intramedullary nail was found to be very useful for the treatment of osteoporotic distal radius fractures, although
a long-term follow-up is still necessary.
The Effect of an Unrepaired Ulnar Styloid Base Fracture on Outcome after Operative Treatment of a Distal Radius Fracture
Institution where the work was prepared: Massachusetts General Hospital, Boston, MA, USA
Jesse Jupiter; David Ring; J Sebastiaan Souer; Massachusetts General Hospital
Purpose:
The indications for ORIF of an ulnar styloid base fracture in association with fracture of the distal radius are debated. We tested the hypothesis that there is no
difference in motion or function in patients with untreated ulnar styloid base fractures compared to patients with no ulnar fracture.
Methods:
Seventy-four matched pairs of patients, one with an ulnar styloid base fracture and the other with no ulna fracture, were culled from a prospective cohort study
of plate and screw fixation of the distal radius. Patient pairs were matched for age, gender, AO fracture type, and injury mechanism. The two cohorts were
analyzed for differences in motion, grip strength, pain, Gartland and Werley Score, DASH and SF-36 at 6, 12, and 24 months follow-up.
Results:
Patients with an ulnar styloid base fracture had slightly but significantly less motion (styloid fracture vs. no styloid fracture) in the arc of forearm rotation at twoyear follow up (164 vs. 171 degrees; p=0.03), pronation at six months follow up (80 vs. 84 degrees; p=0.05), supination at six months (77 vs. 82 degrees;
p=0.03), and radio-ulnar deviation at six months (75.9% vs. 84.3% of opposite arm; p=0,04), but had less pain at one-year follow-up (0.5 vs. 1.0; p=0.04).
All other comparisons at all other time points showed no significant differences.
Conclusion:
Patients with distal radius fractures treated with open reduction and internal fixation that have an unrepaired base of ulnar styloid fracture are nearly identical
to patients with no ulnar fracture. The small differences in motion and pain were inconsistent across time, small enough to be of questionable clinical relevance,
did not correlate with self-rated disability or physician rated outcome scores.
Significance:
Routine internal fixation of an ulnar styloid base fracture is not recommended.
Corrective Osteotomy for Intra-Articular Malunion of the Distal Part of the Radius
Institution where the work was prepared: Ootawara Red Cross Hospital, 2-7-3 Sumiyoshi-cho Ootawara-city Tochigi pref, Japan
Hirokazu Tochigi, MD1; Kazuki Satou, MD, PhD2; Hirofumi Yoshida, MD1; Toshiyasu Nakamura, MD, PhD2; Hiroyasu Ikegami, MD, PhD3; Yoshiaki
Toyama, MD, PhD3; (1)Ohtawara Red Cross Hospital, (2)keio University, (3)Keio University
Corrective osteotomy is an appealing treatment for malunited articular fractures of the distal part of the radius since articular incongruity may be the factor most
strongly associated with arthrosis and diminished function after such fractures. However, malunion cases of distal radial intra-articular fractures treated with wrist
fusion or total wrist arthroplasty were often observed. Enthusiasm for osteotomy has been limited by concerns regarding the difficulty of the technique and the
potential for additional injury ,osteonecrosis, and nonunion. The purpose of this report was to present the experience of surgeons with intra-articular osteotomies
for these injuries, with an emphasis on the techniques and outcomes.
Material and Methods
Seven skeletally mature patients were evaluated at an average of eleven months after corrective osteotomy for intra-articular malunion of the distal part of the
radius. The indication for the osteotomy included articular incongruity of >2mm as measured on a posteroanterior radiograph. According to AO classification,
there were two B2, one B3, two C1,two C2. The average interval from the injury to the osteotomy was six months. Preoperative range of motion averaged
38°of wrist extension, 35°of wrist flexion, 50°of supination, 69°of pronation. Preoperative grip strength averaged 15% of that the contralateral side. As a general rule, osteotomy was performed at the original fracture site. The articular reduction was carefully monitored with image intensification. The osteotomy was
secured with screws alone in one patient (with the addition of external fixator), plate and screws in six patients. Autogenous bone graft was applied in all
patients.
Results
All of the osteotomy sites had healed without evidence of osteonecrosis. One patient had a rupture of the extensor pollicis longus, which was treated with a tendon transfer. The final range of motion averaged 63°of wrist extention, 53°of wrist flexion, 72°of pronation, 81°of supination. The final grip strength averaged
77% of that on the contralateral side. The rate of good results was 43% according to a modification of the rating system of Green and O’Brien.
Conclusions
The results of corrective osteotomy for the treatment of intra-articular malunion are comparable with those of osteotomy for the treatment of the extra-articular
malunion. Intra-articular osteotomy can be performed with acceptable safety and efficacy, it improves wrist function, and it may help to limit the need for salvage procedures such as partial or total wrist arthrodesis.
69
Three-dimensional Corrective Osteotomy of Malunited Fractures of the Upper Extremity Using a Novel Computer Simulation
System and a Custom-designed Surgical Device
Tsuyoshi Murase, MD1; Kunihiro Oka, MD1; Hisao Moritomo1; Akira Goto, MD1; Sayuri Arimitsu1; Yukari Takeyasu1; Junichi Miyake1; Kazuomi
Sugamoto, MD1; Hideki Yoshikawa, MD1; Kozo Shimada, MD2; (1)Osaka University, (2)Osaka Koseinenkin Hospital
Background:
Three-dimensional (3D) anatomical correction is desirable for treatment of long bone deformity of upper extremity. We developed an original system including
a 3D computer simulation program and a custom-made surgical device designed on the basis of simulation to achieve accurate results. In this study, we have
investigated the clinical application of this system and preliminary results for corrective osteotomy of malunited fractures of the upper extremity.
Methods:
Twenty-two patients with long bone deformities of the upper extremities (four cubitus varus deformities, ten malunited forearm fractures, and eight malunited
distal radial fractures) participated in this study. 3D computer models of the affected and contralateral normal bones were constructed using data from computed tomography. The 3D deformity axis and accurate amount of deformity around it were quantified by comparing these models, and a 3D deformity correction was simulated. A custom-made osteotomy template was designed and manufactured to reproduce the preoperative simulation during actual surgery.
When we performed surgeries, we placed the template on the bone surface, cut the bone through a slit on the template, and corrected the deformity as preoperatively simulated, which was followed by internal fixation. All patients underwent radiographic and clinical evaluations before surgery and at the most
recent follow-up.
Results:
Corrective osteotomy was achieved as simulated in all the cases. Bony union occurred in all the patients within 6 months. Regarding cubitus varus deformity,
the average humeral-elbow-wrist and tilting angles (i.e., the anterior tilt of the articular condyle of the distal humerus) were 2° and 28°, respectively, after surgery. Radiographic examination showed that the angular deformities of malunited forearm fractures were nearly nonexistent after surgery. All radiographic
parameters for malunited distal radius fractures were normalized. The range of forearm rotation in cases of forearm malunion and that of wrist flexion-extension in cases of malunited distal radius improved after surgery.
Conclusions:
Corrective osteotomy for bone deformities of the upper extremity using a computer simulation and custom-designed osteotomy template accurately corrects the
deformity and consequently improves the clinical symptoms.
Does Delayed Fixation of Non-Displaced Scaphoid Fractures Affect Union Rate
Institution where the work was prepared: Naval Medical Center San Diego, San Diego, CA, USA
Nathan Hammel, MD; Leo Kroonen, MD; Eric Venn-Watson, MD; Edton Ganal, MD; Brian Fitzgerald, MD; Eric Hofmeister, MD; Michael Thompson, MD,
PhD; NMCSD
Background:
Scaphoid fractures are common upper extremity fractures which can lead to painful non-union. Surgical treatment of non-displaced fractures has led to equivalent union
rates as cast treatment although many studies have examined the beneficial effects of surgical fixation on the time to union and return to sport or work. Delayed union
of both operative and non-operative treatment can be a difficult problem usually requiring additional surgery. This IRB approved, retrospective study attempts to address
a difference in union rates for acute, non-displaced fractures treated operatively within 3 weeks of injury or greater than 3 weeks after injury.
Material and Methods:
28 operatively treated non-displaced scaphoid fractures with adequate follow up were identified from our records of operatively treated acute scaphoid fractures by the 3 senior authors over a two year period. Of these patients, 17 were treated within 21 days, at an average of 8 days after injury. Eleven were treated more than 21 days from injury at an average of 47 days. These groups were similar demographically. There were more associated injuries in the early
treatment group (5 of 17). The fractures were of the scaphoid waist in 14 of 17 in the early treatment group and in 5 of 11 in the delayed treatment group. In
the delayed treatment group there were 5 proximal pole fractures. Fixation was carried out through an appropriately placed percutaneous or open approach.
Headless, variable pitch compression screws were used. The outcome of development of non-union was established by clinical and radiographic data analyzed by a senior author.
Results:
One of seventeen patients treated early went on to a non-union for a rate of 6%. One of 11 patients in the delayed treatment group developed a non-union
for a rate of 9%.
Discussion:
Our study evidences an expected union rate for non-displaced fractures despite a delay in treatment and an unfavorable fracture location mix..
Patterns of Upper Extremity Injury in Operation Iraqi Freedom
Institution where the work was prepared: Naval Medical Center, San Diego, CA, USA
Leo T. Kroonen, MD; Kevin Kuhn; Anatoly Hernandez; Naval Medical Center San Diego
Introduction:
While there has been some literature documenting general demographics of injuries from the current conflict in Iraq, to our knowledge there has been no study
specifically quantifying and describing the patterns of injury to the upper extremity. The purpose of our study was to evaluate wounding patterns to upper
extremity in active duty service members evacuated to a major tertiary care medical facility after sustaining injuries in Operation Iraqi Freedom.
Methods:
After obtaining approval by the Institutional Review Board, data was retrospectively collected for all casualties returning to our tertiary care facility between
April 2003 and July 2006. All patients with an injury to the upper extremity were analyzed. We used simple descriptive statistics to quantify the portion of the
upper extremity affected, mechanism of injury, open or closed injury, bony involvement, associated neurologic injury to the extremity, presence of infection,
total number of days hospitalized at our facility, and presence of deep vein thrombosis.
Results:
Data were recorded for total of 365 casualties received at our facility. Of these casuaties, 134 had sustained injuries to the upper extremity. Injuries involving
the shoulder (21/15.7%), brachium (26/19.4%), elbow (19/14.2%), forearm (37/27.6%), wrist (18/13.4%) and hand (53/39.6%). The mechanism of injury
involved blunt trauma (34 patients/25.4%), blast injuries (68/50.1%) and burn injuries (9/6.7%). Positive wound cultures were found in 22 cases (16.4%). 90
cases (67.2%) involved a bony injury, with 52 open fractures (57.8%) and 43 closed fractures (47.8%). Injuries to neurovascular structures were present in 29
patients (21.6%). Deep vein thrombosis was found in three patients (2.2%).
Discussion:
Advances in body armor, trauma care and evacuation systems have resulted in the survival of more casualties in the current conflicts than any other previous
wars. A critical analysis of the patterns of injury to upper extremity is useful in order to identify potential areas for prevention, and to familiarize the upper
extremity surgeon with the nature of these combat injuries. Our study indicates that, at least at the tertiary care level, upper extremity injuries represent the
majority of orthopedic injuries. They often result from blunt trauma and blast injuries. A high index of suspicion should exist for concomitant infection and/or
nerve injury. Familiarity with the nature of these injuries will assist the upper extremity surgeon in rendering appropriate treatment.
70
Wrist and DRUJ Arthroscopy findings in Distal Radius Fractures: Treatment and Frequency of
Ulnar Styloid Process Fractures and Triangular Fibrocartilage Complex (TFCC) Injuries
Institution where the work was prepared: Yukihiko Obara, Tokyo, Japan
Yukihiko Obara; Saitama Social insurance hospital; Eiko Yamabe, MD; Hiratsuka City Hospital; Astuo Kawakita; Nerima General Hospital
TFCC injury often accompanies distal radius fracture. As part of the treatment of distal radius fractures, arthroscopy was performed to assess TFCC injury, and
the incidence of ulnar styloid process fractures and TFCC injuries was ascertained.
Subjects and Methods:
The subjects included 49 patients who underwent surgery for distal radius fractures. The patients’ average age was 57.3 years. For treatment of the distal radius
fracture, a locking plate was used. For ulnar styloid process fracture with DRUJ instability, pinning was performed, and for TFCC fovea detachment without
ulnar styloid process fracture, direct-vision TFCC was also performed in 9 hands. The clinical results were assessed using Mayo modified wrist scores. The type
and frequency of ulnar styloid process fracture, the type and frequency of TFCC injury, and the clinical results were investigated.
Results:
An ulnar styloid process fracture was seen in 27 hands. A TFCC injury was seen in 35 hands, involving the: disc proper in 19 hands, radial edge in 10 hands,
and fovea in 11 hands. DRUJ arthroscopy showed TFCC ulnar facet detachment in 11 hands. The 14 patients with distal radius fractures without TFCC injury
were young (average age: 45.3 years), while the 35 patients with distal radius fractures and TFCC injury were elderly (average age: 62.1 years). Ulnar styloid
fracture was observed in 27 hands (average age: 58.0 years) and absent in 22 hands (average age: 56.7 years). DRUJ arthroscopy was performed in 35
patients, and TFCC fovea detachment was first seen by arthroscopy in 13 hands (average age: 70.8 years), but TFCC detachment was not seen in 21 hands
(average age: 54.1 years). The occurrence of TFCC fovea detachment was not related to ulnar styloid process fracture. The average clinical score was 87.3 points.
Discussion:
The present study confirmed that the incidence of TFCC injury in distal radius fractures is high (71.4%). Furthermore, DRUJ arthroscopy confirmed TFCC fovea detachment in 38%. The average age of these patients was high, and the incidence of degenerative injury was believed to be high. However, the incidence of untreated
TFCC fovea detachment was unexpectedly high, and favorable results were obtained by performing TFCC suturing in addition. In the future, when treating distal radius
fractures, arthroscopy should be performed to accurately assess the site of injury, following which appropriate treatment should be administered.
Biomechanical analysis of an air-cell equipped plastic splint (Aircast) versus conventional plaster splint in a distal radius fracture model
Institution where the work was prepared: Mayo Clinic , Rochester, MN, USA
[authors]Shian Chao Tay, MD, MS1; Kristin Zhao2; Kai-Nan An2; William P. Cooney2; (1)Singapore General Hospital, (2)Mayo Clinic
Background:
Despite the plethora of surgical treatment options available for definitive treatment of distal radius fractures, acute treatment, and in some cases, definitive treatment is still based on splint immobilization.
Aim:
The aim of this biomechanical study is to determine the efficacy of fracture stabilization that is afforded by a polyethylene forearm-based wrist splint, StabilAir
Wrist Fracture Brace or Aircast, equipped with inflatable air-cells, as compared to a conventional plaster splint. The hypothesis is that distal radius fracture stabilization provided by Aircast wrist brace is equivalent to conventional plaster splints.
Method:
Five right sawbone forearm models and one cadaveric wrist with distal radius fractures (Universal Type IIA) were tested. A custom testing apparatus was built
to hold the forearm and a pneumatic force was applied across the metacarpal heads. Fracture displacement was monitored with an optoelectric tracking device
synchronized with the load data. The models were tested from 0 to 1.7 kg of load in three conditions : unsplinted control; modified sugar-tong plaster splint
treatment; Aircast wrist brace treatment.
Results:
There was no significant difference in mean fracture displacements between modified sugar-tong plaster splint treatment and Aircast wrist brace treatment in
both sawbone and cadaveric models.
Conclusion:
Our study validates the efficacy of the Aircast wrist brace in a biomechanical model. Clinical assessment of the brace is currently in progress for acute, undisplaced and reduced, stable distal radius fractures, and for the post operative support of open reduction internal fixation of distal radius fractures.
Does Vacuum Assisted Wound Closure Affect Tissue Pressures Following Forearm
Fasciotomy for Compartment Syndrome? A Cadaver Model
Institution where the work was prepared: William Beaumont Hospital, Royal Oak, MI, USA
Rachel S. Rohde, MD; Nicholas J. Cook, MD; Gregory V. Sobol, MD; William Beaumont Hospital
Introduction:
Compartment syndrome occurs when pressures within tissue compartments increase enough to compromise perfusion of structures within the confined spaces.
Surgical decompression via fasciotomy lowers these pressures allowing reperfusion, however, edematous tissues often preclude primary wound closure.
Temporary wound coverage following fasciotomy traditionally has involved application of sterile non-adherent dressings until definitive wound coverage is feasible. Recently, vacuum assisted wound closure devices (VAC) have gained popularity for wound coverage following fasciotomy. However, the effect of applying a negative pressure environment to tissues recently challenged by increased pressures is unknown. The purpose of this study was to determine the effect of
VAC dressing placement on post-fasciotomy compartment pressures.
Materials & Methods:
Fourteen fresh-frozen cadaveric upper extremities were obtained. Ten were transhumeral amputations, while four remained attached to the cadaver torso.
Simulated forearm compartment syndromes were induced by infusion of Hespan. Pressures at defined proximal, middle, and distal locations in each forearm
were recorded prior to and following fasciotomy and after placement of the vacuum assisted closure device. Statistical analysis was performed using
Randomized Complete Block Design (RCBD).
Results:
There was no statistically significant difference in average pressure with regard to side (right versus left arm) or location of pressure catheter within the arm
(proximal, middle, distal). There was no significant difference in the average pressure immediately following fasciotomy compared to that after VAC placement
among specimens within each amputation group; however, there was a statistically significant difference in the pressure change following VAC application
between the two types of amputations (p<0.05).
Conclusion:
Placement of a vacuum assisted wound closure device following fasciotomy for forearm compartment syndrome in a cadaver model does not significantly
change compartment pressures. Whether similar pressure consistency is observed clinically in patients treated with VAC following fasciotomy for compartment
syndrome currently is being investigated.
71
A New Test for Evaluating Acute Ulnar Collateral Ligament Injuries of the Thumb
Institution where the work was prepared: University of New Mexico Medical School, Albuquerque, NM, USA
Deana Mercer, MD; John Veitch, MD; Keikhosrow Firoozbakhsh, PhD; Amanda Medoro, MS; Alicia Lacovara, BS; University of New Mexico
Purpose:
Traumatic dislocation of the thumb metacarpal phalangeal (MCP) joint can cause a spectrum of injuries to the ulnar collateral ligament complex. Evaluation of
the extent of injury to the ulnar collateral ligament complex of the thumb MCP joint is difficult to determine. Radiologic testing is expensive and may delay treatment. It has been alluded to by Smith that the extent of dorsal-volar stability at the thumb MCP joint may provide insight into the structures that have been compromised due to injury. This biomechanical study explores the amount of dorsal-volar instability at the thumb MCP joint with sequential sectioning of the structures that provide ulnar stability at the thumb MCP joint.
Methods:
Fifteen fresh frozen cadaver hands (8 male and 7 female, ages 38 to 59) were used in this study. The thumb MCP joint in all specimens were disease free. A
specially designed jig was used to secure the specimens in place and to uniformly measure the thumb MCP joint anterior-posterior translation. Load was applied
dorsally and volarly and displacement measured. A fixed force of 10N was applied to the proximal phalanx. The moment arm was kept constant throughout
the experiment at 1 cm, measured distal to the thumb MCP joint. The displacement was consistently measured at 2 cm distal to the joint. There were three groups
tested (1) thumb MCP joint ulnar structures intact prior to sectioning (intact group), (2) thumb MCP joint with ulnar collateral ligament sectioned (MC group) (3)
and thumb MCP joint with ulnar collateral ligament and accessory collateral ligament sectioned (MC+ group). Load was applied to the intact group, MC group
and MC+ group. Sequence of loading was randomized.
Results:
The mean and standard deviation were 7.13±4.62mm for the intact, 12.06±4.96 mm for the MC, and 19.86±5.00 mm for the MC+ groups. The differences
between the groups were statistically significant (p<0.05) using a 2-tailed paired student t-test. This analysis showed that the measured displacements in the MC and
MC+ groups were, respectively, 1.69 times and 2.78 times higher than those of the intact group (p<0.001).
Discussion:
This biomechanical cadaveric study demonstrates a statistically significant difference in dorsal-volar translation of the thumb MCP joint with increasing disruption of the ulnar collateral ligament complex. The dorsal-volar translation test may help determine the extent of thumb MCP ulnar complex injury and help guide
appropriate treatment.
72
AAHS Concurrent Scientific Paper Session B-1
Treatment of Symptomatic Neuromas of the Dorsal Radial Sensory Nerve using
a Resorbable Nerve Conduit
Institution where the work was prepared: Thomas Jefferson, Philadelphia, PA, USA
A. Lee Osterman, MD; Sergio Rodriguez; John Taras; Thomas Jefferson University
Established symptomatic neuromas of the dorsal radial sensory nerve are difficult problems for which no ideal treatment exists. This paper studied the role of
neurolysis and wrapping of the neuroma in a resorbable collagen conduit.
21 patients, 7M,14F ; average age of 33 years (20-52) met the entry criteria: intractable DRSN pain ; failure of time , desensitization, and neuroleptic medication; positive electrical studies or a surgically documented DRSN injury. All had DRSN neurolysis and wrapping of the neuroma segment with a NeuraGen®
Nerve Guide. Results were evaluated clinically, by visual analog scale, and by DASH questionnaire.
The dominant hand in 52%. 11 had previous surgery to the radial wrist including 4 direct injuries and repair to the DRSN; 7 cases of indirect injury including
Dequervain’s release, CMC arthroplasty, lipoma resection, ORIF distal radius fracture, and dog bite. The 10 closed injuries related to crush injury, percutaneous
needles, radial fracture, and casting . 17/21 has preop electrical studies. All had preop pain management including desensitization and neuroleptics, 17/21
had lidocaine, 12/21 had steroid injection. 2 patients on narcotic medication .The median time from original injury to surgery was 8 months (4-37).The condition was work related in 5 ; litigation active in 4.
Mean FU 2.8 years ( 1.2-4.5). No patient was lost to FU. 90% (19/21) were improved and 95% would repeat the surgery. In 19/ 21 hypersensitivity was
improved and patients were postoperatively able to tolerate watchbands, bracelets and sleeves. Pre and postop 2PD and Semmes monofilament measurements
were variable and not significantly different but all sensory maps identified the DRSN distribution and tended to improve. Subjectively preop numbness
decreased in 66%.
Preop TInels decreased from 100% to 38%. Visual analog scales(0-10) improved both at rest and in activity: rest 5 to 0.7; activity 7 to 1.8. Dash improved
71+/-22 to 29+/- 18. Wrist ROM Improved in flexIon, radial and ulnar deviation. Grip strength improved 61% to 92%. Key and Tip pinch showed similar
data: 55% to 84%, 62% to 88%. Work return : 6 not working rtw usual job; 2 not working rtw modified; ; 7 working stayed working;. 4 high level athletes
were able to return to their sport
In summary, neurolysis and wrapping with a resorbable collagen tube is effective in significantly improving the symptomatic neuroma of the DRSN. It is simple to perform, avoids ablation of the nerve and the harvesting of other tissues. One drawback is the expense of the conduit..
Intra - and Inter-Examiner Variability in Performing Tinel’s Test
Kenneth R. Means, MD; Curtis National Hand Center; Eric H. Williams, MD; Dellon Institute for Peripheral Nerve Surgery: Baltimore. Clinical Instructor;
Johns Hopkins University School of Medicine; Scott Lifchez, MD; Johns Hopkins University School of Medicine; Reg Dunn; Union Memorial Hospital; A. Lee
Dellon, MD, PhD; Dellon Institute for Peripheral Nerve Surgery
Though initially used to detect nerve regeneration, the Hoffman-Tinel sign was adopted in the early 1950’s to also detect sites of nerve compression. There have
been few attempts to standardize Tinel’s test. The goal of this study was to evaluate the intra- and inter-examiner variability in the range of forces created using
different Tinel’s test techniques.
Methods:
Eight clinicians, consisting of two experienced hand and peripheral nerve surgeons (>10 years in practice), three junior hand and peripheral nerve attending surgeons
(1-3 years in practice), and three surgeons in training (plastic or orthopedic surgery residents or hand fellows) were included in the study. A Sensotec load cell with a
detection range of 0-100 lbs was used to record the forces generated during the testing. Three different Tinel-type maneuvers were evaluated: 1) striking the load cell
using the middle finger only, 2) using the index and middle finger together as a “double finger” strike, and 3) preloading with the opposite thumb and then striking the
thumb. Examiners were instructed to use their customary range of force during the testing. Each participant performed three sets of five strikes per technique. Participants
were blinded from the load cell recordings. Data was recorded using Labview (National Instruments, Austin, TX) software. Graphic and statistical analysis was performed
with the R-Project software.
Results:
Intra-examiner: There was a significant difference within nearly all examiners between the range of force they generated with the middle or double finger technique and that which they generated using the pre-load technique (see graph). There was also a difference within nearly all examiners when comparing the
range of forces using the middle finger and double finger techniques. Inter-examiner: There were large differences in the range of forces produced by the various examiners for each technique.
Conclusion:
There has been no standardization for eliciting the Hoffman-Tinel sign. This study demonstrates that there are considerable intra- and inter-examiner differences in the range of forces generated during a lab simulation for multiple Tinel’s techniques that are used in clinical practice. This variability may be responsible for clinical differences in the ability to obtain a Hoffman-Tinel sign in a patient between examiners and may partially explain the inconsistency in sensitivity and specificity reported for Tinel’s test in the literature. Further research on standardization is needed and should be used for any studies that employ Tinel’s
test as part of the study protocol.
73
Outcomes of Single Versus Double Nerve Transfers for Elbow Flexion
Brian T. Carlsen, MD; Michelle Kircher; Robert J. Spinner; Allen T. Bishop; Alexander Y. Shin; Mayo Clinic
Background:
Restoration of elbow flexion after upper brachial plexus injury can be restored with a single nerve transfer to the biceps branch of the musculocutaneous nerve (MCN)
from an ulnar nerve fascicle or a double nerve transfer with an additional nerve transfer to the brachialis branch of the MCN from a median nerve fascicle.
Purpose:
Compare the outcomes of single and double nerve transfers for elbow flexion.
Methods:
A retrospective review was performed of all patients with paralytic loss of elbow flexion receiving nerve transfer to restore elbow flexion. Single and double
nerve transfers were compared in regard to injury level, elbow flexion, supination, and grip strengths, and DASH scores. Elbow flexion and supination torque
strength were measured quantitatively in six single and thirteen double nerve transfer patients.
Results:
Fifty-five patients (23 single, 32 double) underwent nerve transfer to restore elbow flexion. The mean time from injury to operation was similar (178 days, single
vs. 181 days, double). Double nerve transfer patients trended toward improved elbow flexion strength (21% vs. 16%, single) when compared to the contralateral side (p=NS). MRC grade improved to 4 or better in 14/21 single and 24/30 double nerve transfer patients. Supination strength tended to be greater in double nerve transfer patients (37% of contralateral side) compared to single nerve transfer patients (22% of contralateral side) (p= NS). Grip strength was greater
in the double nerve transfer patients (42%, single vs. 63% double, p < 0.05) compared to the contralateral side. Pre-operative DASH scores were significantly
greater in single (51.3) vs. double (37.3) nerve transfer patients. Single nerve transfer patients had a greater improvement in DASH scores (20.2 vs. 8.3, p<0.05).
Final mean DASH scores were similar in the 2 groups (29.5, single vs. 28.6, double). The injury level was different between the two groups with 19/23 single
nerve transfer patients having injury beyond the C5-6 level and only 16/32 of double nerve transfer patients with >C5-6 injury (Chi probability, 0.041).
Conclusions:
Outcomes are similar for single and double nerve transfers for elbow flexion. Double nerve transfer patients have greater grip strength and tend toward improved
elbow flexion and supination strength. Patients appropriate for double nerve transfer tend to have less severe injury and lower pre-operative DASH scores than single nerve transfer patients. Single nerve transfer patients had a greater improvement in DASH scores to a level similar to double nerve transfer patients.
Mirza Single-Portal Endoscopic Carpal Tunnel Release. A Prospective, Randomized Study
Abigail Zamora, BA; Charles S Day, MD; Albert Yeh, BA; Miguel Ramirez, MD; Beth Israel Deaconess Medical Center/Harvard Medical School
Hypothesis:
The Mirza palmar uniportal carpal tunnel release technique involves a small longitudinal incision in the palm that allows identification of the superficial palmar
arch and associated branches of the median nerve. This should reduce risk for complications that occasionally arise in traditional endoscopic release techniques.
Methods:
All patients were enrolled at a single tertiary care academic medical center. Patients were randomized to either the open or Mirza endoscopic limbs.
Exclusionary criteria included other surgical procedures on the affected limb. Follow up visits were performed blindly at 2, 4, 8, and 12 weeks post-operatively. Outcome measurements included the standardized Disabilities of the Arm, Shoulder, and Hand (DASH) survey, grip and pinch strength, sensory tests (2-pt.
discrimination, monofilament), and a patient satisfaction questionnaire. Statistical analysis was performed with repeated measures ANOVA.
Results:
A total of 48 patients (mean age 54, range 26-81; 36 women) have been enrolled so far. A total of 50 hands underwent surgery (23 endoscopic, 27 open),
with the average incision size being 1.67 cm and 2.87 cm. respectively. There was no significant difference between the two procedures with respect to improvement of sensation, DASH scores, grip strength, pinch strength, return to work, overall patient satisfaction, scar tenderness, or return to daily functions throughout follow-up (p>0.05). However, patients who underwent the open procedure reported significantly better pain relief at the 2, 4, and 12 week visits than those
who underwent the endoscopic procedure. There were no surgical complications in either group. When asked before surgery, 24 patients preferred the smaller incision, 21 had no preference, and 1 preferred the larger incision.
Conclusions:
Contrary to previous studies, there was no difference in the complication rate between the Mirza endoscopic release and open release. Patients preferred the
smaller incision despite there being minimal difference in functional outcome. Patients with the open release reported greater pain relief.
Summary Sentence:
Patients preferred the endoscopic incision over the open incision despite minimal difference in functional outcome. Patients who underwent the open procedure
experience greater pain relief. There was no difference in the complication rate between the Mirza and open procedures.
The 6-item CTS Symptoms Scale - A Brief Outcomes Measure for Carpal Tunnel Syndrome
Institution where the work was prepared: Department of Orthopedics Hässleholm-Kristianstad, Hässleholm, Sweden
Isam Atroshi, MD, PhD; Hässleholm and Kristianstad Hospitals; Per-Erik Lyrén, MSc; Umeå University; Christina Gummesson, PT, PhD; Lund University
Purpose:
We used item response theory (IRT) to derive a brief carpal tunnel syndrome (CTS) symptoms scale from a previously validated scale.
Methods:
Preoperative questionnaires, including the CTS 11-item symptom severity and 8-item functional status scales, from 693 patients (71% women) undergoing carpal
tunnel release were analyzed. The scales were examined using reliability and factor analyses and IRT including differential item functioning (DIF) concerning
gender.
Results:
Factor analysis of the two scales combined showed presence of a dominant factor related to function including all functional status and two symptom severity
items, and three other factors with symptom severity items. The IRT Partial Credit Model (PCM) fit the data well. Four items were removed from the symptom
severity scale and two items were merged creating the new 6-item CTS symptoms scale. Factor analysis showed one dominant factor explaining 60% of the
variance. Reliability was high (alpha = 0.86). The PCM properly fit the new scale and IRT person separation reliability was 0.85. One item displayed significant but very small DIF.
Conclusions:
The 6-item CTS symptoms scale has good measurement properties and can be used for outcome evaluation in CTS.
74
Early Clinical Outcomes with the Use of Decellularized Nerve Allograft for Repair
of Sensory Defects within the Upper Extremity
Furkan Erol Karabekmez, MD; Ahmet Duymaz, MD; Samir Mardini; Steven L. Moran; Mayo Clinic
Introduction:
Nerve conduits have become an established option for repair of sensory deficits of up to 2cm. More recently, decellularized nerve allograft has also been advocated as
an option for nerve repair, however no clinical studies have examined its efficacy for sensory nerve defects. The aim of this study was to examine our early experience
with the use of decellularized nerve allograft for repair of segmental nerve defects within the hand and fingers.
From July 2007 to March 2008, 9 patients who had 10 nerve gaps were treated surgically using Axogen® nerve allograft. They were 8 digital and 2 ulnar nerve defects.
The etiologies of the nerve defects were traumatic nerve transection in 6 defects and neuroma resection and reconstruction in 4 defects. Eight of the affected nerves were
sensory and two were mixed, containing motor and sensory fibers. The outcomes were evaluated with moving and static two point discrimination tests. Implantation sites
were also evaluated for any signs of infection, rejection or graft extrusion.
Result:
There were 8 men and 2 women with a mean age of 42 years (23-65). Mean nerve graft length was 2.3 cm with a range of 0.5-3. Mean follow up time was 4 months (2-5).
Average two point discriminations were 7.2 mm moving and 7.5 mm static at last recorded follow-up. No rejection or infection sign were seen around the graft material and
sensory improvement was observed in all of the patients despite this short term follow up. Re-exploration of 2 fingers was required for flexor tendon rupture in one and flexor
tendon tenolysis in the other. In both cases the nerve allograft was visualized and appeared well incorporated in the repair site.
Conclusion:
Decellularized nerve allografts were capable of returning adequate sensation in nerve defects ranging from 0.5-3 cm. There were no cases of infection or rejection and material handling properties were excellent. Decellularized nerve allograft may provide an option for segmental nerve gaps beyond 2cm. Randomized comparative studies will be
required to determine efficacy in comparison to collagen conduits or nerve autograft..
Effect of Profession on Duration of Symptoms Prior to Carpal Tunnel Release Surgery
Institution where the work was prepared: Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
Eric Makhni; Harvard Medical School/Beth Israel Deaconness Medical Center; Charles S. Day; Harvard Medical School
Introduction:
The effect of patient career/profession on the duration of symptoms prior to carpal tunnel release has not been investigated. This study sought to determine if such a correlation exists.
Methods:
All records of patients seen and examined in our clinic between January 2005-January 2007 were reviewed. Those patients with the diagnosis of carpal tunnel syndrome
were included in this review. Records were reviewed for demographic data (including patient profession, such as “serice,” “retired,” “medical,” “laborer,” “clerical,” or
“other,”) as well as data pertaining to timing of symptom onset, disease diagnosis, and operative repair (if applicable).
Results:
A total of 245 patients carried the diagnosis of carpal tunnel syndrome among all records reviewed. 122 of these patients ultimately had corrective surgery, while the remaining
123 underwent only conservative management. The average age of those patients who received operative management was significantly higher than those who underwent only
conservative management (56.3 years vs. 50.3 years; p<0.001). When considering patient profession, there were no significant difference among any of the above-mentioned
groups when considering fraction undergoing surgery (p=0.55), duration of symptoms (p=0.61), or number of visits prior to diagnosis (p=0.8). However, there was a trend
towards an increasing number of visits before surgery for those in the medical profession (p=0.1).
Conclusions:
Those undergoing operative repair for carpal tunnel syndrome are older than those undergoing conservative management only. Because the two treatment groups were similar with respect to duration of symptoms prior to surgery, age may play an important role when considering operative repair. Further, those in the medical profession had
more clinic visits pre-operatively than other counterparts, signifying an poentially increased threshold for conservative management.
Comparison of Anterior Transposition and In Situ Decompression for Ulnar Nerve Compression
at the Elbow: One Surgeon’s Experience
Institution where the work was prepared: Johns Hopkins University School of Medicine, Baltimore, MD, USA
Ron Gutmark, BA; Elizabeth N. Le, BS; E. Gene Deune, MD; Johns Hopkins University School of Medicine
Objective:
The most optimal surgical technique for treatment of cubital tunnel syndrome (CTS) has not been conclusively determined. This study examined 38 operations for the treatment of CTS using in-situ decompression (IS) (n=16) or anterior submuscular transposition (ASM) (n=22).
Methods:
A retrospective chart review on consecutive operations from 2/2000 to 9/2007 was undertaken on 34 patients, 18 males and 16 females with an average age of 44.7.
These patients underwent either IS (n=20) or ASM (n=22). 42.1% of patients had operations on their dominant hands. Severity of ulnar nerve compression prior to and
after surgery was determined by objective measures including pinch and grip strength, two point discrimination, and electromyographical (EMG) data, and by subjective
measures including the Dellon scoring system and patients’ questionnaire (average time to survey was 54 months).
Results:
The reoperation rate for the IS group was 0% (0/16) and 18.2% (4/22) for the ASM group. In the IS group, average Dellon scores decreased after surgery by 1.09
points compared with a decrease of 0.18 points for the ASM group. For patients in the IS group, two point discrimination decreased by 2.11 mm after surgery compared
to a decrease of 1.94 mm in the ASM group. Grip and pinch strength for the IS group increased by 39.71 and 3.35 lbs, respectively, compared to an increase of 10.18
and 3.53 lbs, respectively, for the ASM group. There were no clear differences between males and females using the various criteria, except with grip and pinch strength,
which showed greater improvement with ASM in males vs. females. Those in the younger group (<49) who underwent ASM showed greater improvement in all criteria
over the older group. EMG showed greater improvement in the ASM group compared to the IS group with regard to latency and velocity, but the IS group showed greater
improvement in amplitude (Table 1).
Conclusion:
This study illustrates a superior improvement in several key indicators of efficacy in the IS group when compared to the ASM group. However, EMG latency and velocity
and sensory conduction velocity showed better performance than the IS group, but this apparently did not correlate with subjective symptoms. This is likely due to the more
invasive nature of ASM and the choice of bed in which the nerve is placed.
75
Revision Surgery after Carpal Tunnel Release Using Fascio-Cutaneous Island Flaps
Institution where the work was prepared: University Hospital Bern, Bern, Switzerland
Matthias Traub, MD; Esther Voegelin; University Hospital Bern
Hypothesis:
The use of fascio-cutaneous island flaps in the treatment of recurrent or persistent carpal tunnel compression syndrome (CTS) reduces painful symptoms by providing a
tension-free gliding tissue cover.
Methods:
From 1997-2007, 16 patients (9 women, 7 men, aged 26 to 77 years with a mean of 56.8 years) had 18 operations for either recurrent or persistent CTS, or neuropathic pain
syndrome. All patients were treated with neurolysis of the scarred median nerve followed by either a reversed posterior interosseous (n= 12) or an ulnar artery perforator flap
(n= 6) depending on extension and localisation of scarring. The patients were evaluated pre- and postoperatively using a pain visual analogue scale and the DASH score.
Sensibility, motor dysfunction, pain and success of the treatment were classified as good, improved or bad. Postoperative ENMG examinations were performed.
Results:
Patient mean follow-up was 23.8 months (1.7 to 93.5). The pain evaluation showed a statistically significant improvement (p<0.005) decreasing from a mean value of 6.7
to 1.5. The DASH score was significantly improved postoperatively (p< 0.005). The best results were observed in patients without extensive preliminary median nerve damage. The duration of symptoms before re-operation did not influence the outcome. Eight patients demonstrated good, six improved and two patients maintained poor results.
The two patients with poor results suffered from extremely scarred and injured median nerves following previous surgery.
Summary:
• Protective coverage of the median nerve by use of a fascio-cutaneous island flap after failure of carpal tunnel release provides a tension-free gliding tissue cover and
reduces the risk of adhesions
• It reduces painful symptoms effectively, however does not guarantee total pain relief in all patients
• Pain relief and functional recovery strongly depend on the pre-existing condition of the median nerve
• Postoperative ENMG show release of compression but no recovery of axonal damage
Application of Fibrin Glue in Microvascular Anastomoses: Comparative Analysis with the Conventional Suture Technique Using a Free Flap
Model
Institution where the work was prepared: Instituto de Ortopedia e Traumatologia da USP, São Paulo, Brazil
Alvaro B. Cho, MD; Mattar Júnior Rames; Faculdade de Medicina da USP
Background:
Several studies have already reported the utilization of fibrin glue in microvascular anastomoses to minimize the number of sutures and to decrease the operative time.
Despite the good results obtained in most of these experiments, its clinical application has not launched. The aim of this study was to clarify the controversies around the
safeness of fibrin glue application in microvascular anastomoses and also to demonstrate the potential benefits of fibrin glue application in a realistic free flap model.
Methods:
Twenty-seven rabbits were used in this study. The experimental model consisted of a free groin flap transfer to the anterior cervical region. The flap’s circulation was restored
by means of an end-to-side anastomosis between the femoral and carotid arteries, and an end-to-end anastomosis between the femoral and external jugular veins. The first
seven animals were used in a pilot study to test the experimental model and train the surgical procedure. The remaining 20 rabbits were divided into two groups according to
the anastomosis technique: Group I (conventional suture) and Group II (fibrin glue). The animals were kept alive for at least of two weeks when the anastomoses were reexplored. We used the Student‘s “t” test to compare the quantitative parametric data and the Mann Whitney “u” test to compare the quantitative non-parametric data.
Results:
The number of sutures required to complete the arterial and venous anastomoses was reduced in 39% and 37% in group II, respectively. The mean arterial anastomosis time was
4,5 minutes shorter in the fibrin glue anastomosis group (p = 0,00004). The mean venous anastomosis time was 6,4 minutes shorter in group II (p = 0,0001). The ischemic time
of the flaps was 11,2 minutes shorter in the fibrin glue anastomosis group (p = 0,001). The total operative time was also shortened by 15,6 minutes in group II (p = 0,0395).
Conclusions:
Both arterial and venous anastomoses were benefited from fibrin glue application, which made them easier and faster to perform. Despite the significant amount of suture reduction, the anastomoses maintained adequate patency rates and mechanical strength and the flaps’survival rate was not negatively affected. In this study, the application of fibrin
glue in microvascular anastomoses was safe and reliable. The risk-benefit ratio of fibrin glue application in microvascular anastomoses is favorable for its use.
Pedicled Descending Branch Muscle-sparing Latissimus Dorsi Flap for Trunk and Upper Extremity Reconstruction
Corrine Wong, MBBS, MRCS; Michel Saint-Cyr, MD; UT Southwestern Medical Center, Dallas
Background:
The major blood supply of the latissimus dorsi muscle flap is based on the descending and transverse branches of the thoracodorsal artery. This segmental blood supply allows
the muscle to be split and harvested based solely on vascularization from the descending branch, thus sparing the latissimus dorsi muscle function. This article reports the use of
the descending branch muscle-sparing latissimus dorsi myocutaneous flap in reconstructing defects on the trunk and upper extremities.
Methods:
Five patients with defects on the trunk or upper extremities had soft tissue reconstruction with a pedicled descending branch muscle-sparing latissimus dorsi myocutaneous flap.
A transverse skin paddle design was used in all cases. All flaps were performed by the senior author. Complications were recorded, and range of motion analysis was performed comparing operated and non-operated sides during follow-up appointments.
Results:
The descending branch muscle-sparing latissimus dorsi flap was used for reconstruction of the: chest wall (2), axilla (2) and upper extremity (1). The skin paddles harvested ranged
from 15x7cm to 24x9cm. All donor sites were closed primarily. There was one case of minor wound dehiscence on the donor site and one case of wound infection (reconstruction
was for chronic, severe axillary hidradenitis suppuritiva). There were no incidences of seroma. In all cases, there was no difference in strength or range of motion around the shoulder
joint when comparing the operated to the non-operated side.
Conclusion:
The pedicled descending branch muscle-sparing latissimus dorsi myocutaneous flap with a transversely orientated skin paddle results in minimal functional deficit of the
donor site, absence of seroma, low rate of flap complications and an aesthetically acceptable scar.
76
Forearm Osseous Reconstruction with Vascularized Free Fibula Grafts
Brian T. Carlsen, MD; Scott Thompson, BA; Steven L. Moran, MD; Allen T. Bishop, MD; Alexander Y. Shin, MD; Mayo Clinic
Background:
Vascularized osseous reconstruction is indicated for large skeletal defects. Studies reporting the outcome of vascularized fibula for forearm reconstruction are sparse and
most include other anatomic locations.
Purpose:
Report the outcomes of forearm reconstruction with vascularized fibula grafts.
Methods:
A retrospective review was performed of 21 consecutive patients receiving vascularized fibula grafts for forearm reconstruction from 1980 through 2007 at a large academic institution. Patients were analyzed in regard to the etiology and location of the defect. Endpoints included time to skeletal union, post-operative complications, range
of motion, and DASH scores.
Results:
Twenty-one patients (15 male, 6 female) with an average age of 26.7 (6-59) were identified. The etiologies of the defect included trauma (5), infection (4), tumor (11),
and congenital pseudoarthrosis (1). The average defect size was 8.0 cm with a range from 4-13 cm. Eight patients had reconstruction of a single bone (radius or ulna),
six patients had construction of a single-bone forearm with the graft, ten patients had fusion of the wrist with the graft, and three patients had a combination of wrist fusion
and one-bone forearm construction. At the time of the study, sixteen patients were available for fusion analysis. Primary union was achieved in 10/16 (62.5%) patients
at an average of 5.7 months. Six of sixteen (37.5%) patients required additional procedures to achieve union at one of the osteosynthesis sites with union achieved at an
average of 28 months after the initial operation in this group. One patient had an additional vascularized corticoperiosteal bone graft from the medial femoral condyle.
Seven of 10 patients with reconstruction of tumor defects achieved primary union, vs. two of four patients following reconstruction of infection and trauma related defects.
DASH surveys were able to be completed on nine patients at an average of 12 years after injury. DASH scores averaged 15.2 for this group. Postoperative complications were common, occurring in 13/21 (62%) patients. There was one early microvascular failure with conversion to non-vascularized bone graft. Other complications
included nonunion (7), infection (3), tendon adhesion (2), radioulnar synostosis (1), delayed microvascular thrombosis (1), fracture of the fibula graft (1), plate
fracture/hardware failure (1), median nerve neurapraxia with delayed recovery (1), and superficial radial nerve neuroma (1).
Conclusion:
Osseous reconstruction of the forearm with a vascularized fibula graft is a complex procedure associated with major complications. It can provide satisfactory outcomes
in patients with limited reconstructive options.
Intravascular Stenting Method for Fingertip Replantation
Institution where the work was prepared: Narushima Mitsunaga, Tokyo, Japan
Jun Araki; Narushima Narushima, MD; Tokyo University
Remarkable progress has been made in microsurgery. However, fingertip replantation following amputation has not gained much popularity because of its technical difficulty.
We have developed the intravascular stenting (IVaS) method, in which a nylon monofilament is placed inside the vessel lumen to act as a temporary stent, facilitating anastomosis completion. We performed 9 fingertip replantations using the IVaS method. Intravascular stent size varied from 4-0 to 6-0 (0.199-0.07mm diameter). There were no cases in
which the back wall of a vessel became inadvertently caught in the anastomosis. The overall survival rate for distal digital replants was 88 % (8/9 replants). It is very difficult to
evenly anastomose vessels of differing diameter, especially on a supermicrosurgical scale. In this respect, the IVaS method plays a role in stably anchoring the two vessel ends,
allowing for the even spacing of suture knots, even in vessels of different caliber. Because of its ease of use and exactitude, many surgeons may be able to use the IVaS method
to reliably complete small anastomoses in fingertip replantations.
Triangular Flaps: a Modified Technique for the Correction of Congenital Constriction Ring Syndrome
Institution where the work was prepared: Chang Gung Memorial Hospital, Kaohsiong, Taiwan
Lynn PL Tan, MBBS, MRCS, MMed; Singapore General Hospital; Yuan-Cheng Chiang, MD; Chang Gung University and Chang Gung Memorial Hospital
Background:
Congenital constriction ring syndrome (CCRS) is a congenital anomaly with a wide spectrum of clinical presentation. The accepted method of correcting a circular constriction is to excise the deep part of the constriction, and break the line of the circular scar with multiple Z- or W-plasties. Specific correction of soft tissue is recommended concurrently, to better correct the “sandglass” deformity.
Here we describe a technique using triangular flaps to correct the deformity in 7 patients with constriction ring syndrome, involving either the upper or lower limbs. In this
technique, triangular flaps can be introduced either proximal or distal to the ring, depending on the limb circumference, to better correct the contour deformity.
Results:
In all 7 patients, a normal extremity contour was obtained, with complete elimination of the deformity caused by the constriction ring. A mean follow-up of 34 months
revealed an aesthetically acceptable scar, with no case of recurrence.
Conclusion:
Triangular flaps designed either proximal or distal to the constriction ring is able to correct the contour deformity of the limbs with better versatility and aesthetic results.
Patient Reported Outcome Following a Traumatic Peripheral Nerve Injury
Institution where the work was prepared: University of Toronto and York University, Toronto, ON, Canada
Christine B. Novak, PT, MS, PhD(c)1; Dimitri J. Anastakis, MD1; Dorcas E. Beaton, PhD1; Joel Katz, PhD2; (1)University of Toronto, (2)York University, University of
Toronto
Outcome following traumatic peripheral nerve injury (PNI) is variable and the degree of disability depends on multiple factors related to the injury and to the patient.
Purpose:
The purpose of this study was to evaluate patient reported outcome and the presence of pain and disability following an upper extremity PNI.
Methods:
Following Research Ethics Board approval, the medical charts were reviewed of patients who met the following inclusion criteria: adult patients who at the initial consult
were at least 6 months from an upper extremity traumatic PNI and had completed a DASH questionnaire and the SF-36. For the SF-36, comparisons were made between
the Canadian norms and the nerve injured patients. Patients were classified as having high pain if they exceeded 2 standard deviations from the normative data.
Comparisons of the DASH scores was performed using t-tests or a one-way ANOVA between the following independent variables; pain, workers’ compensation or litigation involvement, gender, time since injury, nerve injured. Multiple linear regression was used to evaluate the variables (gender, workers’ compensation or litigation
involvement, dominant hand injured, time since injury, age, nerve injured, bodily pain) that predicted outcome (DASH).
Results:
There were 84 patients (19 women, 65 men) with a mean age 38 years (sd 14 yrs). The mean time following injury was 4 years and the most frequent injury was to the
brachial plexus (n = 27). For all 8 domains of the SF-36 and the physical and mental component scale, the mean values of the nerve injured patients indicated significantly more impairment than the normative values (p < 0.001). The mean DASH score was 52, which indicated an elevated level of disability. Patients with more bodily
pain (p < 0.001) and brachial plexus injuries (p = 0.023) had significantly more disability. Using manual backward elimination and 0.1 level of significance for removal,
the final model contained the predictor variables bodily pain (beta = -.481, p < 0.001), age (beta = .424, p = 0.002) and nerve injured (beta = -4.683, p = 0.024) and
45% of the variance was explained with this model.
Conclusion:
In patients with traumatic peripheral nerve injuries, disability as measured by the DASH is associated with more bodily pain, older age and brachial plexus involvement.
Assessment of chronic pain following PNI and further investigation into the associated factors may provide an opportunity for efficacious treatment and better health related quality of life.
77
AAHS Concurrent Scientific Paper Session B-2
Arthroscopic Transosseous Repair of the Ulnar Disruption of the TFCC to the Ulnar Fovea
Institution where the work was prepared: Department of Orthopaedic Surgery, Keio University, Tokyo, Japan
Toshiyasu Nakamura, MD, PhD; Kazuki Sato, MD, PhD; Masato Okazaki, MD; Yoshiaki Toyama, MD, PhD; Hiroyasu Ikegami, MD, PhD; Keio University
Treatment of the DRUJ instability due to ulnar disruption of the TFCC is a challenging issue. We described here an arthroscopic outside-in suturing (trans-ulnar
suturing) of the ulnar disruption of the TFCC to the ulnar fovea.
Technique:
When the disrupted TFCC from the fovea was diagnosed through the radiocarpal or DRUJ arthroscopy, the TFCC was tightly reattached to the fovea through
two tunnels made from the outer cortex of the ulna to the center of the fovea using outside-in pullout technique with double 3-0 polyester sutures (Ticron or
Etibond). Before suturing, the fovea area was refreshed by arthroscopic shaver via DRUJ portal.
Patients:
We underwent the arthroscopic repair of the TFCC in 21 wrists. Age ranged 14-53 (average 27), 8 male and 13 female were included. There were 10 right
and 11 left wrists. TFCC tears were ulnar peripheral + horizontal in 6, fovea avulsion in 14, and proximal slit in 1. Periods from initial injury to the surgery
were 6-48 months (average 30). Pain, range of rotation and DRUJ instability were evaluated.
Results:
All patients complained pain preoperatively. Pain disappeared in 14 wrists, remained in 3 and recurred in 4. There were no loss of forearm rotation pre- and
postoperatively. Preoperative DRUJ instability was noted as „b in 2, + in 6, ++ in 13 and postoperatively, 16 wrists indicated no instability. We obtained excellent results in 13, good in 2, fair in 3 and poor in 3.
Conclusion:
Arthroscopic trans-ulnar suturing technique is promising procedure in ulnar disruption of the TFCC with DRUJ instability.
Efficacy and Safety of Clostridial Collagenase for Injection in Patients with Dupuytren’s
Contracture: Results of a Phase III Trial
Institution where the work was prepared: Indiana Hand Center, Indianapolis, IN, USA
F. Thomas D. Kaplan, MD1; Bronier L. Costas, MD1; Vincent R. Hentz, MD2; Lawrence C. Hurst3; John Lubahn4; (1)Indiana Hand Center, (2)Stanford
University Medical Center, (3)SUNY-Stony Brook, (4)Hamot Medical Center
Purpose:
Injectable Clostridial collagenase (AA4500) is an investigational, minimally invasive, nonsurgical treatment for Dupuytren’s contracture (DC). Single-center trials demonstrated that injection of AA4500 into Dupuytren’s cords corrected metacarpophalangeal (MP) and proximal interphalangeal (PIP) joint contracture to
0°Æ-5°Æ of normal in most cases; no placebo-injected cords achieved this response. Two phase III studies (Collagenase Option for Reduction of Dupuytren’s
[CORD] I and CORD II) are evaluating the efficacy and safety of AA4500 in a larger patient population. Results of the double-blind phase of CORD I are presented here.
Methods:
CORD I is being conducted at 16 US sites: an open-label extension is ongoing for patients who require additional therapy for failure of placebo or involvement of other joints. Enrollment required MP and/or PIP flexion deformities °Ã20°Æ. Patients received °Â3 0.58-mg collagenase injections in the cord affecting a primary joint at 4 week intervals. Follow-up occurred 1 day, 1 week, and 1 month after each injection. Primary efficacy variable was primary joint correction to 0°Æ-5°Æ of normal after the last injection. Cords affecting subsequent joints could be injected. Flexion contracture, range of motion, grip strength,
and adverse events were evaluated.
Results:
In the randomized, double-blind, placebo-controlled phase of CORD I, 306 adults (80% male; mean age 63±9.5 years) who had a mean duration of symptoms of 61±77 months and a mean baseline contracture of 50¨¬±20¨¬ were evaluable for efficacy. 62% had one hand affected; 38% had bilateral disease.
58% of patients had no prior treatment; 38% had surgery; and 14% had physical therapy. Patients receiving AA4500 achieved a 79.3% reduction (from 50.2¨¬
to 12.2¨¬) in joint contracture vs 8.6% (from 49.1¨¬ to 45.7¨¬) on placebo (P<0.001). Post-treatment joint contracture was °Â25¨¬ in 82.2% of patients and
within 0°Æ-5¨¬ of normal (the primary end-point) in 64% of patients. In contrast, only 6.8% of patients on placebo achieved joint contracture to within 0°Æ5¨¬ of normal (P<0.001). The most common adverse events included pain, swelling, bruising, and pruritis at the injection site, and transient lymph node swelling
and pain. No systemic allergic reactions were noted. Three SAEs possibly related to drug occurred (2 tendon ruptures and 1 complex regional pain syndrome).
Conclusions:
The results of this phase III study confirm previous clinical trials (J Hand Surg 2007;32A:767), which showed that injectable Clostridial collagenase effectively
and safely corrected or significantly improved MP and PIP contractures in most patients with 1 or more DC-affected joints.
78
Treatment of Scaphoid Nonunions Using Vascularized Bone Grafts Transplanted Through a Dorsal Approach
Institution where the work was prepared: Kyoto University Hospital, Kyoto, Japan
Ryosuke Kakinoki, MD, PhD1; Ryosuke Ikeguchi1; Takashi Nakamura1; Taiichi Matsumoto, MD2; (1)Kyoto University, (2)Kurashiki Central Hospital
Purpose:
To report surgical outcomes of 17 patients with scaphoid nonunions using vascularized bone grafts transplanted dorsally.
Patients and Methods:
17 scaphoid nonunions in 17 patients (16 males and a female) underwent surgery using vascularized bone grafts supplied by the 1-2 intercompartmental
supraretinacular arteries. All vascularized bone grafts were transplanted through the dorsal capsule, leaving the palmar radiocarpal ligament intact. The mean
age of the patients at the time of the surgery was 27 years (range, 13-59). The mean interval between the injury and surgery was 4.3 years (range, 8 weeks
to 42 years). Four patients had had surgery for the scaphoid before the present operations. Arcs of the dorsiflexion, palmar flexion, radial deviation and ulnar
deviation and the grip strength of the bilateral wrists were measured before surgery and at the time of the final follow-up in each patient. The arc angles and
grip strength of the affected hands were expressed as percentages of those of the contralateral hand. The radiolunate angles of the affected wrists were measured on the postoperative and preoperative plain X-ray films. The postoperative status of the affected wrists was assessed using a modified Mayo Wrist Scores.
Results:
Bone union was obtained in all patients except a patient. The average interval between the surgery and bone union was 11.9 weeks (range, 8-30 weeks) in
the remaining 13 patients. The DISI deformity was corrected after the operations in all patients having shown DISI deformity before the surgery. The respective
preoperative and postoperative average arcs of the affected wrists were 80±12% and 74±14% in the dorsiflexion, 76±17% and 62±18% in the palmar flexion, 55±21% and 53±26 in the radial deviation, 94±23% and 75±12% in the ulnar deviation. The preoperative and postoperative grip strength were 71±17%
and 84±17%, respectively. The palmar flexion and ulnar deviation significantly decreased postoperatively. The radiolunate angles significantly decreased from
–10.2±9.7?preoperatively to –1.2±9.4?postoperatively in the patients having had the DISI deformity before surgery. The mean modified Mayo Wrist Score
was 74 (range, 60-90). There were no patients who developed avascular necrosis of the proximal scaphoid.
Conclusion:
Vascualrized bone grafts transplanted to scaphoid nonunions dorsally corrected the DISI deformity and prevented the development of the avascular necrosis of
the proximal scaphoid.
Underutilization of Upper Extremity Reconstruction for Persons with Tetraplegia:
The Patient Perspective
Institution where the work was prepared: Rehabilitation Institute of Chicago, Chicago, IL, USA
Michael S. Bednar, MD1; Rebecca Ozzelie, OTR/L2; Elizabeth Jordan, OTR/L, CHT1; (1)Loyola University - Chicago, (2)Rehab Institute of Chicago
While it is estimated that 65% of persons with tetraplegia would benefit from upper extremity reconstruction, fewer than 10% actually have the procedure performed. Recent studies suggest barriers to these procedures include an inadequate referral network between physiatrists and surgeons and the hestitancy of
physiatrists to recommend these procedures to their patients. At our institution, tetraplegic patients are seen in a multidisciplinary clinic, including both physiatry and hand surgery. The physiatrists encourage all patients to be evaluated. Despite this, only 18% of patients who are candidates for upper extremity reconstruction choose to have the procedures. The goal of this study is to survey the patients who chose not to have surgery to determine reasons for their choice.
Over 5 years, 113 patients were evaluated. Twenty eight patients were ineligible for surgery. Fifteen had surgery. Of the remaining 85, 70 were contacted to
participate in this study and 30 agreed. Of the participants, the mean age was 36 years old, 90% were male. An IRB approved telephone survey, based on
the instrument designed by Curtin, was administered by one of two occupational therapists. Questions included those derived from the disability dimension of
the Standford Health Assessment Questionnaire to determine functional status. All questions were answered on a 4 point scale. Data was analyzed using a
cluster analysis.
Four clusters of patient attitudes were identified. The first, named “conflicted” had the lowest time since injury (6.4 years). Their concerns centered on having
to rely on others, waiting for recovery, and not wanting more surgery. The second cluster, named “waiting for the cure”, stated this was their only concern. They
had the highest level of function. They had the smallest increase in interest in having surgery after attending clinic of any of the clusters. The third cluster, named
“too costly”, cited cost, relying on others, and business of life as barriers. This group had the lowest ADL scores and the longest time since injury. The last cluster, named “questioning”, stated they still didn’t understand the benefit of the surgery. This group had the largest increase in interest in surgery after attending
clinic.
Each of the four groups presented with unique issues and concerns regarding their decision to not have upper extremity reconstruction. Each of the groups
requires differing degrees of education about the procedures and rehabilitation, insurance issues, and social support.
The Point Prevalence Of The DRUJ Injuries Complicating Perilunate Injuries
Institution where the work was prepared: Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
Tuna Ozyurekoglu, MD; Paolo Sassu; Sandy Hanlin; Christine M. Kleinert Institute for Hand and Microsurgery
Purpose:
To find out the prevalence of the distal radioulnar joint related injuries associated with Perilunate dislocations at their initial presentation to the hand surgeon.
Methods:
Twenty-two perilunate dislocations in 21 consecutive patients were evaluated and treated at our Level 1 Trauma Center between November 2003 and July
2006. Two female and 19 male patients with a mean age of 37 (range 19-59) formed the group. Nine patients were involved in motor vehicle accidents, 12
patients fell from height. There were 8 perilunate dislocations and 14 transscaphoid fracture dislocations in the group. Five had contralateral wrist injuries.
Pathologic findings were analyzed for each wrist by reviewing the patient charts, operative notes and digital images. The distal radioulnar joint (DRUJ) related injuries were defined by the presence of a fracture at the base of the ulna styloid, widening or subluxation of the DRUJ, distal radioulnar instability noted
or treated at the time of initial surgery.
Results:
Eleven wrists (50%) showed DRUJ related injuries. Eight of these had a displaced fracture at the base of the ulna styloid, one had a flake of bone at the prestyloid area, one had a fracture of the ulnar shaft with DRUJ instability, and one had widening of the DRUJ. Three non-displaced ulna styloid fractures were not
included. Of the eleven DRUJ related injuries only eight received initial treatment. Four wrists showed ulnar translocation of the lunate, four had associated fracture of the radius; eight had a fracture line through the triquetrum.
Conclusion:
The point prevalence of the DRUJ injuries complicating Perilunate injuries at their initial presentation was estimated as 0.50, with a confidence interval of 28.871.2. Because the initial appraisal of both the osseous and ligamentous pathology is important in the management of perilunate dislocations DRUJ related
injuries should also be addressed at their initial presentation.
79
Endoscopic Cubital Tunnel Recurrence Rates
Institution where the work was prepared: Orthopaedic Specialists, Davenport, IA, USA
Tyson Cobb, MD; Orthopaedic Specialists, PC; Patrick T. Sterbank, PA-C; ORTHOPAEDIC SPECIALISTS, P.C; Jon Lemke, PhD; Genesis Medical Center
Hypothesis:
Endoscopic Cubital Tunnel release has a recurrence rate no greater than open cubital tunnel release.
Methods:
After approval of our institutional review board we reviewed 134 consecutive cases of endoscopic cubital tunnel release in 117 patients. Post operative outcome was measured
by the Modified Bishop classification. A recurrence was identified if the patient was symptom free immediately following surgery but had symptoms reappear after a minimum
3 month post operative period as described by Seradge et al in 1998. Two literature control groups were used from published reports of recurrence rate following open cubital
tunnel release. Seradge, et al reported recurrence in 21 of 160 patients under going cubital tunnel release with medial epicondylectomy at 3 or more months. Lankester and
Giddins reported 1 of 20 patients with recurrence after 10 months with simple decompression.
Results:
Of the 134 cases of Endoscopic Cubital tunnel releases there were 104 cases for 94 patients with 3 month post operative follow-up. There were no exclusions and included concomitant surgeries and co morbidities. The mean follow up time for the 104 cases was 736 days ranging from 92 to 1,766 days. The 94 patients consisted of 58
males (61.70%), 36 females (38.3%), age range from 21-89 and the mean was 49 for males and 47 for females. One case (0.96%) met the criteria for recurrence at 4
months post procedure. Of the 104 cases, 92.31% had more than 4 months follow-up. Data was then compared to the literature control groups used from published
reports of recurrence rates following open cubital tunnel release. Pooled the combined controls had 22 of 180 cases (12.22%) with recurrences. The procedure recurrence
percents varied significantly with p-value = 0.0004. The data was analyzed using STATXACT for an exact test comparing the two recurrence percents.
Summary:
We are 95% confident our true recurrence rate is between 0.02% and 5.24%. Recurrence after Endoscopic Cubital Tunnel release is not greater than recurrence following open cubital tunnel release.
Outcome Following Acute Primary Darrach Resection for Comminuted Fractures of the Distal Ulna at the time of Operative Fixation of
Unstable Fractures of the Distal Radius
Institution where the work was prepared: New York University Hospital for Joint Diseases, New York, NY, USA
David E. Ruchelsman, MD; Keith B. Raskin, MD; Michael E. Rettig, MD; NYU Hospital for Joint Diseases
Background:
Optimal acute management of the highly-comminuted distal ulna head/neck fracture sustained in conjunction with an unstable distal radius fracture requiring operative
fixation is not well-established.
Purpose:
To determine the clinical, radiographic and functional outcomes following acute primary Darrach resection for comminuted distal ulna fractures performed in conjunction
with the operative fixation of unstable distal radius fractures.
Methods:
Between 2000-2007, eleven consecutive patients, mean age 63 years (range, 45-75) were treated for concomitant closed, comminuted, unstable fractures of the distal
radius and ulna metaphysis. All eleven patients underwent acute primary Darrach distal ulna resection through a separate dorsal ulnar incision with ECU tenodesis for
irreparable distal ulna head/neck fractures at the time of operative fixation of the distal radius fracture. According to the Q modifier of the Comprehensive Classification
of Fractures, there were six comminuted fractures of the ulnar neck (Q3), and five fractures of the head/neck (Q5). Operative fixation of the distal radius fracture included volar plate fixation followed by 6 weeks of cast immobilization in four patients, and standard spanning external fixation with supplemental percutaneous Kirschner
wires in seven patients. At a mean of 3.5 years postoperatively, clinical, radiographic, and wrist-specific functional outcome with the modified Gartland and Werley wrist
score were evaluated.
Results:
At latest follow-up, mean wrist range of motion measured 55º flexion, 50º extension, 85º pronation, and 75º supination. Mean grip strength measured 90% of the contralateral, uninjured extremity (range, 55-120).No patient had clinical evidence of ulnar stump instability or symptoms related to the dorsal ulnar sensory nerve. Final
radiographic assessment demonstrated restoration of distal radius articular parameters without ulnar stump instability or ulnar carpal translocation. According to the system of Gartland and Werley as modified by Sarmiento, there were seven excellent and four good results. No patient required a secondary surgical procedure at latest
follow-up.
Conclusion:
Acute primary Darrach resection yields satisfactory clinical, radiographic, and functional results in appropriately selected patients and represents a reliable alternative
when anatomic restoration of the distal ulna/sigmoid notch cannot be achieved. Distal ulna resection concomitant with distal radius fixation may help avoid early or late
secondary procedures related to distal ulna fixation or symptomatic post-traumatic distal radioulnar joint arthrosis.
Low Calcaneal Bone Mineral Density is Associated with a High Risk to Sustain a Distal Radius Fracture – a Population-Based Study
Institution where the work was prepared: Department of Orthopedics Hässleholm-Kristianstad, Hässleholm, Sweden
Isam Atroshi, MD, PhD1; Fredrik Åhlander, MD1; Mats Billsten1; Henrik G. Ahlborg, MD, PhD2; Dan Mellström, MD, PhD3; Claes Ohlsson, MD, PhD3; Östen Ljunggren, MD,
PhD4; Magnus K. Karlsson, MD, PhD2; (1)Hässleholm and Kristianstad Hospitals, (2)Lund University, (3)Gothenburg University, (4)Uppsala University
Introduction:
Osteoporosis is defined by the World Health Organization as a bone mineral density (BMD) T-score below -2.5 measured with a dual-energy X-ray absorptiometry (DXA) total body
scanner. Portable heel scanners have gained increasing interest but their fracture predictive ability is less evaluated. We used a DXA heel scanner to estimate the prevalence of osteoporosis in a population with distal radius fracture and evaluate calcaneal BMD’s predictive ability.
Patients aged 20 to 80 years with distal radius fracture treated at one emergency hospital during two consecutive years were invited to calcaneal BMD measurement. Of 421
eligible patients, 333 (79%) participated; 270 women, mean age 63 (SD 12) years, and 64 men, mean age 54 (15) years. A Calscan DXL heel scanner estimated BMD
(g/cm2) and T-score values. A population-based cohort including 153 women, mean age 58 (13) years, and 305 men, mean age 74 (5) years, served as controls. The comparison between the fracture and control populations involved women 40 to 80 and men 60 to 80 years. The age-specific prevalence of osteoporosis (T-score below -2.5 SD)
was determined and the ability of calcaneal BMD to discriminate between the fracture and normative cohorts was assessed by receiver operating characteristic (ROC) analysis.
Results:
The prevalence of osteoporosis in women aged 40 to 80 years with a distal radius fracture was 32% compared with 16% in the control group (age-adjusted prevalence ratio
(PR) 1.46, 95% CI 1.01-2.11, p=0.046), and in men aged 60 to 80 years were 44% and 6%, respectively (PR 10.5, 95% CI 5.9-18.7, p<0.001). Age-adjusted BMD was lower
in the fracture cohort than the normative cohort; mean difference (95% CI) in women 0.11 (0.10-0.13) and in men 0.13 (0.09-0.18) g/cm2 (p<0.001). One SD lower BMD
was associated with an increased odds ratio (95% CI) for having a distal radius fracture of 1.8 (1.4-2.3) in women and 2.3 (1.6-3.3) in men. The area under ROC curve (95%
CI) was in women 0.63 (0.57-0.69, p<0.001) and in men 0.77 (0.67-0.87, p<0.001).
Conclusions:
The prevalence of osteoporosis based on DXA-measured calcaneal BMD is significantly higher in individuals with a distal radius fracture than in a normative cohort.
Impairment in calcaneal BMD by one SD is associated with approximately doubled risk of a distal radius fracture.
80
Clinical and Radiographic Outcomes Following Utilization of Purpose-Designed Threaded Pins for the Treatment of Extraarticular Distal Radius
Fractures
Institution where the work was prepared: The Philadelphia Hand Center, PC, Philadelphia, PA, USA
John S. Taras, MD; The Philadelphia Hand Center, PC; Joshua Abzug, MD; Hahnemann University Hospital
Hypothesis:
Purpose-designed threaded pins are effective for the treatment of extraarticular distal radius fractures (T-Pin®, Union Surgical, Philadelphia, Pennsylvania).
Methods:
A prospective study was undertaken to evaluate patients with extraarticular distal radius fractures who underwent fixation with threaded pins. Flexion, extension, pronation, supination, and JAMAR grip strength values were recorded. Data from the uninjured extremity provided a baseline by which to compare the patient’s range of motion and strength. Preand postoperative radiographs were performed to assess volar angulation and ulnar variance. Statistical analysis was performed utilizing Signed Ranks test on SPSS.
Results:
67 patients underwent fixation of their extraarticular distal radius fracture with purpose-designed threaded pins. The flexion-extension arc returned to 66% (87 degrees:
42 degrees flexion; 45 degrees extension) of the patients’ normal arc by the 3 month period, and was 83% (119 degrees: flexion 54 degrees; extension 65 degrees) of
normal by 1 year postoperatively. The pronation-supination arc was 83% (142 degrees: 77 pronation; 65 degrees supination) of the contralateral side by 3 months postoperatively and 94% of normal (159 degrees: 83 degrees pronation; 76 degrees supination) by 1 year. JAMAR grip strength at position 3 returned to 72% of normal at
an average of 7 months. Preoperative radiographs demonstrated an average of 11.85 degrees of dorsal angulation and ulnar variance of minus 1 millimeter. The postoperative radiographs showed improvement to an average of 5.22 degrees of volar tilt and ulnar variance of 0.7 millimeters (p<0.05). There were 3 complications reported with 1 loss of reduction in a patient who was weight bearing in that upper extremity.
Summary:
Purpose-designed threaded pins are safe and effective implants for the treatment of extraarticular distal radius fractures. Patients regain 90% of their range of motion by 1 year
postoperatively and 72% of their strength by approximately 6 months postoperatively. Radiographic reduction is improved significantly with regard to radial length and volar tilt.
Outcome of Nonoperative Treatment of Ulnar-Sided Wrist Pain
Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Robert Joseph Goitz, MD; Ali Razfar; John M. Duffy, PAC; Robert Alexander Kaufmann, MD; Deborah Kowalchuk; James Irrgang; Camilo D. Borrero; Jeffrey D.
Towers; University of Pittsburgh Medical Center
Hypothesis:
Patients with acute ulnar-sided wrist pain can be effectively treated with a splint and steroid injection. Physical examination and MRI findings will predict failure of nonoperative treatment.
Methods:
Forty-five patients with less than a three month history of ulnar-sided wrist pain were followed prospectively. All patients underwent a physical examination, radiographs
and MRI. Patients were provided a custom fabricated Muenster splint. If pain continued after 1 month, patients received a steroid injection and continued splint wear for
an additional month. If they continued to have pain, then surgery was offered. Univariate logistic regression was performed to estimate the effect of potential predictors
on the odds of failing non-operative treatment.
Results:
The mean age was 37.5 (range, 12-76 years) and the median duration of symptoms was 1.5 months. Thirty-three patients (75%) associated their pain with a traumatic
event. 40.0% of patients were successfully treated with a splint alone. Nineteen patients received an injection at an average of 34 days following initial presentation. 58%
of injected patients had successful relief of symptoms. 16 patients ultimately underwent surgery and 2 patients that failed splinting and injection deferred surgery for an overall success rate of 60% of this non-operative regiment. The TFCC stress test was the only finding that had a significant effect on the odds (OR 13.6, 95% CI 2.57, 71.86) of
failing non-operative treatment. The likelihood ratio for a positive TFCC stress test was 2.40, which increased the post-test probability of failing non-operative treatment from
40% to 62%. The negative likelihood ratio was 0.18, which decreased the probability of failing non-operative treatment from 40% to 11%.
Summary:
Patients with acute ulnar-sided wrist pain have a 60% chance of successful treatment with a splint and injection. Patients with a positive TFCC stress test have a higher
chance of failing nonoperative treatment and may be better treated with immediate surgery.
Baseline Characteristics of Patients Enrolled in Two Phase III Studies of Injectable Clostridial Collagenase for Dupuytren’s Contracture
Institution where the work was prepared: The Indiana Hand Center, Indianapolis, IN, USA
F. Thomas D. Kaplan, MD; Indiana Hand Center; Marie Badalamente, PhD; SUNY-Stony Brook; Robert N. Hotchkiss, MD; Hospital for Special Surgery; John D.
Lubahn, MD; Hand, Microsurgery and Reconstructive Orthopaedics; Stephen Coleman, MD; Rivercity Hospital; Stephen Hall, MD; Emeritus Research
Purpose:
Prior studies have shown that intralesional injections of Clostridial collagenase (AA4500)—an investigational, minimally invasive, nonsurgical treatment for Dupuytren’s Contracture
(DC)—reduce the degree of contracture in metacarpophalangeal (MP) and proximal interphalangeal (PIP) joints to within 5° of normal in most patients; placebo injections did not
produce this response. The demographics of subjects participating in 2 multicenter, phase III studies comprising randomized, double-blind, placebo-controlled and open-label extension phases investigating the efficacy and safety of Clostridial collagenase are representative of a larger number of patients than previously studied.
Methods:
Studies designated Collagenase Option for Reduction of Dupuytren’s (CORD) I with 16 US sites and CORD II with 5 Australian sites are ongoing. Enrollment required flexion
deformities of ?20° of the MP and/or PIP joints. Patients in the double-blind phase receive up to 3 injections of 0.58 mg of collagenase in the primary joint, at 4-6 week intervals. In the open-label phase, patients receive up to 5 additional injections (up to 3 injections/joint). Patients are to be followed for up to 12 months post first injection.
Results:
Baseline characteristics for the 374 patients enrolled in both studies (Table) are available. Mean age was 63±9.4 years. At time of diagnosis, 21% of patients were <45
years old (mean age, 53±13 years), 45% of patients had a family history of DC. Comorbidities included collagen diseases (knuckle pads [4%,] Ledderhose’s disease [5%,]
Peyronie’s disease [5%]), diabetes (7%), and epilepsy (2%.) Disease was unilateral and bilateral in 60% and 40% of patients, respectively and mean number of affected
joints per patient was 3±2. Mean duration of symptoms was 62±78 months. Mean contracture was 50°±20°, and mean range of motion was 44±20. Overall, 56% of
patients had no treatment prior to study entry. The topline efficacy and safety data for the double-blind phase of CORD I became publicly available in June 2008. Results
from this analysis will be presented.
Conclusions:
Baseline characteristics of this large population of patients with DC are similar to those from previously reported trials investigating Clostridial collagenase. Exceptions
include bilateral disease, which was twice as common in the CORD studies, and frequency of comorbid fibrotic disorders such as Peyronie’s Disease, which were lower
among patients in the CORD studies.
81
Line Scan Diffusion Spectrum of Rat Denervated Skeletal Muscle
Institution where the work was prepared: HIratsuka City Hospital, HIratsuka City, kanagawa, Japan
Eiko Yamabe, MD1; Toshiyasu Nakamura, MD, PhD2; Yukihiko Obara, MD2; Koji Abe, MD2; (1)Hiratsuka City Hospital, (2)Keio University
Introduction:
In case of peripheral nerve palsy such as radial, ulnar, and median nerve injury, denervated skeletal muscle shows increased T2 in the MR images. However,
it takes certain amount of time, typically up to a week, before this change becomes visible. Since the mechanism behind this change is considered to be increased
extracellular fluid (ECF), we hypothesized that the same change can be detected earlier by measuring diffusion. We measured both T2 and apparent diffusion
coefficient (ADC) using peripheral nerve injury model of rats.
Total of 12 male rats were used, weighing approximately 200g each. We made the nerve injury model by cutting the left posterior tibial nerve. At 1, 3, 5, 7,
14, 28 days after the surgery, T2 and ADC of gastrocnemius muscle, which was the target muscle of posterior tibial nerve, were measured using line scan diffusion method on a 1.5T clinical imager
Results:
In the T2 weighted images, it was difficult to recognize the change until 7 days after injury. After two weeks, it became obvious in the T2 weighted images. T2 value
increases gradually over two weeks, while ADC value increases right after injury, and decreases 5 days after injury. Four weeks after injury, ADC returned to normal, but T2 value stayed at high value (Fig. 1). DISCUSSION Although both T2 and ADC are considered to reflect the state of extracellular fluid, our results show
the clear difference between the time courses of T2 and ADC values after injury. Although clear mechanism behind these phenomena is not clear, diffusion MRI
seems to be a better clinical tool for early diagnosis of peripheral nerve injury.
Conclusions:
ADC increased quickly after injury, and was detectable one day after injury. Diffusion MRI can be a useful tool for early detection of peripheral nerve injury.
Anatomical Features of the Pronator Quadratus muscle for the treatment of Distal Radius Fractures with a Palmar Locking Plate
- Cadaveric Study
Naoya Takada; Komaki City Hospital
Purpose:
Minimally invasive osteosynthesis (MIO) with a palmar locking plate is one of the beneficial treatments for distal radius fractures. Since 2004 we have been using this
technique through 2 small skin incisions (1.5-2 cm) without dividing the pronator quadratus (PQ) muscle. However, there has been no report of the cadaveric study
for this procedure. The purpose of this study is to understand the anatomical features of the PQ muscle for reduction of the fracture, plating and inserting screws.
Methods:
Ten forearms of 5 fresh cadaveric specimens were used for this study. A skin incision was made on each of the volar sides of the forearms and the PQ muscle
was exposed. The width (PQW) from the proximal edge of the PQ to the distal edge of it, and the distance (PRD) from the distal edge of the PQ to the joint surface of the distal radius were measured. After inserting the plate (length 86mm) under the PQ, the distal part of the plate was held on the distal part of the radius
and the proximal part of the plate was pulled off with a fixed locking sleeve from the radius. When the muscle fiber of the QP starts to tear, the distance from the
volar cortex of the radius to the proximal edge of the plate was measured.
Result and conclusion:
The average PQW, PRD and PD were 34.5mm (range 25-40mm), 16.5mm (range 15-20mm) and 11.9mm (range 25-40mm). The length of the plate should
be more than 51mm (PQW+PRD) for this procedure to prevent damage to the PQ. For controlling the plate under the PQ it should be performed in the 12mm
area between the PQ and the volar cortex of the radius. It is important to understand the anatomical features of the Pronator Quadratus muscle and the data
given above for the successful MIO and prevention of soft tissue damage.
Profit Margins for Inpatient and Outpatient Orthopedic Procedures: a Comparative Study
Institution where the work was prepared: Beth Israel Deaconess Medical Center, Harvard Medical School, boston, MA, USA
Eric Makhni; Harvard Medical School / Beth Israel Deaconness Medical Center; Charles S. Day; Harvard Medical School
Introduction:
In an era of decreasing reimbursement in the health care system, cost-control becomes elevated in importance. This study sought to determine profit margins
for different orthopedic procedures.
Methods:
We reviewed the costs and revenues of all surgeries in the Department of Orthopedic Surgery over a one year period from July 2004-2005. All procedures
were classified as one fo the following: back, foot/ankle, hand, joints, spine, sports, trauma, or “other.” Further, each surgery was designated as “inpatient”
or “outpatient.” Within each subgroup, the revenue, cost (direct and indirect), and average-length-of-stay (for inpatient procedures) were noted.
Results:
A total of 4117 orthopedic surgeries were performed from July 2004-2005. There were 1933 inpatient procedures and 2184 outpatient procedures. For inpatient cases, the overall average-length-of-stay was 4.6 days. This length of stay was 5.3 for spine and 4.8 each for trauma and joints cases. Hand and back
cases were 2.3 and 2.7, respectively. Profit margins were highest for hand ($2,420) and lowst for joints and trauma (-$464 and -$1,244, respectively). For
outpatient procedures, the most profitable cases were those of hand/wrist ($266). Sports and foot/ankle cases were substantially less profitable ($128 and
$158, respectively), and trauma cases were profitable by only $19. Spine procedures, however, had a profit margin of -$217.
Conclusions:
Even though surgeon reimbursements for different orthopedic sub-specialties are pre-determined, many orthopedic procedures, when taking expenses into consideration, are not profitable for the governing hospital. Of all sub-groups, hand/wrist procedures were the most profitable in both the inpatient and outpatient setting. In the
inpatient setting, increasing length-of-stay may be associated with decreased profits, but serial annual analysis is required to further elucidate this correlation.
82
Modeling of Upper Extremity Problems
Institution where the work was prepared: University of Louisville, Louisville, KY, USA
Steven J. McCabe, MD, MSc; Stephanie Tapp; University of Louisville
Due to the complexity and expense of randomized trials they have not been commonly applied to answer research questions in upper extremity disorders.
Decision analysis can be used to model the management of medical disorders and provides an alternative when randomized trials are not possible or practical. The similarity in the general management principles of many upper extremity inflammatory disorders opens the possibility of creating a generic decision
model that can be easily adapted to a large number of upper extremity conditions providing efficient analysis of management decisions. For example, trigger
digit, DeQuervain’s tenosynovitis, carpal tunnel syndrome, and tennis elbow can all be treated with splinting, oral medication, injection, and surgery.
Markov modeling is a commonly used technique for decision analysis that has features that make it attractive for upper extremity problems. Markov models
are especially suited to evaluate recurring events that are commonly seen in upper extremity care, and the time in a state of health that is also an important
feature of upper extremity care.
Our purpose was to develop a Markov Model that is comprehensive yet flexible enough to evaluate the management of upper extremity inflammatory conditions. One major objective was that the model must be easily adapted to answer multiple questions for a variety of conditions.
We created a Markov model that has the capability to consider treatments such as splinting, injection, and surgery applied in a sequential fashion, each for a
variable amount of time or number of applications. The evaluation of diagnostic tests and cost-effectiveness evaluation are also possible. The model accurately portrays clinical care and can be easily adapted to represent a variety of upper extremity problems by changing the treatments available, the number of
applications or time each treatment is applied, the cost, potential complications, disutility of any treatment, and the efficacy of each treatment.
Using adaptation of this basic decision analysis model, researchers can answer many questions about management of upper extremity disorders
The Determination of Finger Laterality Dominance during Routine Activities
Institution where the work was prepared: University of Missouri, Columbia, MO, USA
Dustin Christiansen, MD; Rukmini Rednam, MD; Steven L. Henry, MD; Stephen H. Colbert, MD; Bradley A. Hubbard; University of Missouri
Background:
Finger injuries and some reconstructive procedures require incisions on, or sacrifice of, a fingertip pulp. We find no objective basis for the dogma regarding
the relative importance of radial and ulnar sensory surfaces of the digits. This study attempts to quantify the use (value) of each half of each digit tip during various activities.
Seventeen volunteers participated in twenty-two routine activities using paint-covered items. Standardized photographs were taken, and the degree of involvement of the radial and ulnar halves of each fingertip was calculated using a template that allowed measurement of the percentage of the half of the fingertip
(hemi-pulp) that was covered in paint. Intra- and inter-digital comparisons were made to determine hemi-pulp and finger dominance.
Results:
One hundred forty-five fingertip uses, or instances, were analyzed, 110 from the dominant hand (22 activities x 5 fingers), and 35 from the non-dominant (7
activities x 5 fingers). A statistically significant preference of the radial or ulnar hemi-pulp was noted in 75 instances, 51.7% of all instances examined. Rates
of laterality dominance were similar between the dominant and non-dominant hands. The thumb accounted for 14 of the 75 significant instances of laterality
dominance (18.67%), with 10 (71.4%) instances of ulnar predominance and 4 (28.6%) favoring the radial. Among the fingertips, the radial hemi-pulp was
favored 53 (86.9%) times, and the ulnar 8 (13.1%) times. Comparison of the entire fingertip of the index, long, and ring fingers revealed a predilection for use
of the more radial finger, except in the case of gripping activities, in which the more ulnar digit was consistently favored. Finally, the ten sensory surfaces of the
dominant hand were ranked based on the means of the percent of the hemi-pulp used across all activities. In decreasing order, they were ulnar thumb, radial
index, radial thumb, radial long, ulnar index, radial ring, radial small, ulnar long, ulnar ring, and ulnar small.
Conclusion:
A significant difference in the side of the fingertip used in the activities examined occurs more than half the time. For the thumb, this is usually the ulnar surface, for the
fingers, the radial. Activities requiring finer hand movements favor use of more radial digits, while strength activities favor the ulnar. The ten sensory surfaces of the
digit tips can be placed in a rank order based on use, which may represent their relative importance for sensory input during the activities examined.
A Case Study of the RSD Or Psudo-Gout Hand and Extremity
Institution where the work was prepared: Mayo Foundation, , Rochester, MN, USA
Celoa Sue Robinsom, BS, in, ED, Cert; Life and Leisure Hand and Physical Therapy
This is a case study of an actual experience of mine when I developed a very painful right wrist after a bump on the dorsum of the right wrist,leaving a bruise, I
am on coumadin due to atrial fibulation and my INR was 3.7. The blood from the bruise intered the right wrist joint producing a great deal of pain and restriction of motion.Being I am a Hand Physical Therapist I thought I was having Reflex Sympathetic Dystrophy. This presentation is how I rehabed my right wrist, hand
and upper extremity emphasizing that a therapist has to be very gentle with the resultant hand, wrist and upper exctremity in order to obtain a fully functional
hand, wrist and upper extremity. I saught help from my Ambulatory Phramist,Marcel D Bizien.Pharm D, PhD at the Kasson Mayo Family Clinic, Kasson, MN,my
General Practioner, Dr.Michael W. Justice MD and a physician that was a Hand Physical Medicine Specialist, Dr Keith Bengtson. MD. With their guidence and
input I have been able to, so far obtain a functional right hand and upper extremity. Throught this presentation my objectives are to empower Hand Occupation
and Physical Therapist with the skills to produce a funtional Hand when the hand, wrist and upper extremity are involved with RSD and /or pseudo-gout.
83
AAHS Poster Presentations
Omental Free Tissue Transfer for Coverage of Complex Upper Extremity and
Hand Defects - The Forgotten Flap
Institution where the work was prepared: Lutheran Genaral Hospital, Chicago, IL, USA
Iris A. Seitz, MD; University of Chicago; Craig S. Williams, MD; Clinical Orthopedic Surgery Northwestern University Feinberg School of Medicine; Thomas
A. Wiedrich, MD; Northwestern University Medical School; Loren Schechter, MD; Lutheran General Hospital
Background:
Free omental tissue transfer is one of the oldest and most versatile reconstructive options for trunk, head and neck, and extremity defect coverage. Its usefulness is due to the flap’s
long vascular pedicle, large vessel size, relatively thin contour, tissue flexibility and large surface area. Most series have focused on use of this tissue for trunk and head and neck
reconstruction. We report our experience with omental free flap coverage of complex upper extremity defects.
A retrospective analysis of 3 cases of omental free flaps for upper extremity reconstruction between 1999 and 2008 was performed. Indication, operative technique and outcome were evaluated.
Results:
All patients were male; age range was 20-38 years. Indications included tissue defects due to severe trauma or infection. One patient sustained a crush injury resulting in near complete amputation of both hands requiring revascularisation. The second patient had a crush, degloving injury of the dorsal hand. The third patient had
massive tissue loss of the forearm and arm due to necrotizing fasciitis and compartment syndrome. All patients had several operations including revascularisation,
wound debridement and fixation of associated fractures. The mean defect size was 280cm2 with all patients achieving complete wound coverage with omental free
flap and split thickness skin graft. No flap loss or major complications were noted. One patient required additional surgery secondary to osteomyelitis 4 months after
the initial injury, and a subsequent debulking procedure 9 months later. The second patient had a superficial wound infection at the abdominal donor site that healed
with local care. Laparoscopic assisted omental free flap harvest was performed in all cases in conjunction with the general surgery team. Mean follow-up was 3 years.
Conclusion:
The omental free flap is a valuable, often overlooked reconstructive option. The long vascular pedicle and large amount of pliable, well vascularized tissue allow
the flap to be aggressively contoured to meet the needs of complex three dimensional defects. In addition,laparoscopic assisted harvest may aid with flap dissection and result in reduced donor site morbidity.
Surgical Outcome of Middle Phalanx Fractures
Institution where the work was prepared: Department of Hand Surgery, Singapore General Hospital, Singapore, Singapore
Hui Ling Chia, MRCS, MBBS; Shian Chao Tay; Beng Hoi Tan; Singapore General Hospital
Aim:
There are many excellent reports on the outcome of middle phalangeal base fractures. However, there is a paucity of reports on surgical outcomes specific to
fractures of the shaft and/or condyles of the middle phalanx (MP). A retrospective review was thus performed to evaluate the outcome of surgically treated middle phalangeal shaft and condylar fractures.
Method:
All patients with surgery performed in 2005 and 2006 for MP fractures involving the shaft or condyles were included. Main outcome measures included clinical, functional and radiographic assessments. Using the modified Al-Qattan’s classification, fracture displacement was graded before and after surgical fixation. Outcomes were classified into excellent, good and fair (modified from Barton, 1979). Patients with open or multiple fractures (on the same finger) were
excluded.
Result:
A total of 76 MP fractures were operated on 65 consecutive patients. Of these, 20 (26.3%) were MP fractures involving the shaft and/or condyles (3 condylar, 8 subcondylar, and 9 shaft). Moderately displaced (Type IIB) fractures were the commonest. Methods of fixation ranged from mini-plate and screws (25%),
interfragmentary screw (45%), interosseous wire with kirschner wire (20%) or a combination (10%). Except for one lateral approach, all fractures were
approached dorsally. Based on the modified Al-Qattan’s classification, 15 of 20 fractures had excellent reduction after fixation. Mean follow-up time was 196.8
days. Seventeen of 20 fractures were followed to union with three fractures lost to follow-up before union. The average time to union was 113.5 days. The
mean distal interphalangeal joint (DIPJ) motion was 40 degrees. One-third of patients were found to have an extensor lag of the DIPJ (range 15-40 degrees).
All patients with extensor lag had undergone either plate or interosseous wire fixation and most of them (83.3%) of them occurred in patients with condylar
and subcondylar fractures. 30% of patients had good outcomes, and 70% fair outcomes according to the modified Barton’s criteria. The single patient with lateral approach with lateral plating had a fair outcome. Mean return to work was 45.9 days in our series.
Conclusion:
Surgical outcome of MP fractures of the shaft or condyles was complicated by a high rate of DIPJ stiffness and extensor lag. This is despite early rehabilitation.
Poor prognostic factors include condylar and subcondylar fractures, and the severity of initial fracture displacement. Fractures which were amenable to interfragmentary screw fixations alone, tended to have better outcomes.
84
Nerve Grafting in Upper Extremity
Harilaos T. Sakellarides, MD; Boston University School of Medicine
Purpose:
To demonstrate that severe injuries of the hand can be treated by nerve grafting with very satisfactory end results.
Methods:
Previously applied methods of nerve grafting had disappointing results. Over a span of 15 years, new techniques have been used, namely microscope, microsurgical techniques, and fine suture material. Evaluation of nerve repairs was according to the British method. Experimental work proved: 1) The detrimental
role of tension at the suture line. 2) The deleterios effect of postoperative stretching on successful functonal recovery. 3) Regeneration axons advanced more
easily through nerve grafts of 2cm with two tension free anastomoses compared with a single suture under tension. The epineurium was the primary source of
connective tissue proliferation.
Results:
Motor recovery for Meidan nerve: Excellent 40%; Good 40%; Fair 20%. Ulnar nerve: Excellent 38%; Good 40%; Fair 22%. Radial nerve: Excellent 42%; Good
38%; Fair 20%.
Conclusions:
Encouraging results were obtained providing certain details of the method are strectly followed.
Latissimus Dorsi Transfer for Massive Rotator Cuff Tears via an axillary approach
Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA
Bradley Palmer, MD; Mark Baratz; Allegheny General Hospital
Massive tears of the rotator cuff are a challenge for both the patient and surgeon. Treatment options include debridement (1) and repair with or without tendon graft
(2, 4). When repair is not feasible the latissimus dorsi can be transferred in those patients who have good passive motion and minimal wear of the glenohumeral joint
(6, 7,8,12). This article describes a technique borrowed from the plastic surgery literature to harvest the tendon using lighted retractors through a small transverse incision beneath the axilla. This technique gave adequate visualilzation to release the tendon, mobilize the muscle and pass the tendon to anterolateral incision. The comestic result is superior to previously described approaches.
Complication of Hand Extensor Tendon Lacerations in Emergency Caesarean Section
Institution where the work was prepared: Advocate Lutheran General Hospital, Park Ridge, IL, USA
Taizoon Baxamusa, MD, FACS1; Preetha Prazad, MD2; Henry Mangurten, MD2; (1)University of Illinois at Chicago, (2)Advocate Lutheran General
Children’s Hospital
Accidental fetal injury is a serious but underreported complication during caesarean delivery, particularly after one that is emergent. The most commonly documented injury is skin laceration. Though the majority of reported lacerations are superficial, a few are deep and require surgical intervention. We report a
case of severe multiple extensor tendon lacerations with open metacarpophalangeal joint injuries sustained at the time of an emergency caesarean delivery
that resulted in excellent functional outcome following surgical repair.
Community-acquired Methacillin-resistant Staphylococcus Aureus in the Suburban Plastic Surgery Hand Patient Population
Institution where the work was prepared: Lehigh Valley Hospital, Allentown, PA, USA
Marshall Miles, DO; Terry-Lynn Burger, RN, BSN; Robert X. Murphy Jr, MD, MS; Lehigh Valley Hospital
Introduction:
Methacillin-resistant staphylococcus aureus (MRSA) is a frequent cause of infection in the postoperative patient. We observed increasing numbers of community-acquired MRSA infections in patients presenting to the hand surgery service at our suburban academic center. It is an important issue, as unsuspected community-acquired MRSA hand infections can too easily be admitted to the hospital, inadequately treated, and allow for nosocomial spread. The objective of this
study was to examine the trend in the incidence of community-acquired MRSA hand infections in the plastic surgery patient, in order to sensitize practitioners
to have a high index of suspicion for this entity and promote early recognition and treatment of this organism.
Methods:
A multi-hospital retrospective chart review was undertaken to compare the incidence of community-acquired infections in plastic surgery hand patients from
2000 through 2007.
Results:
Only two community hand MRSA infections were treated in 2000, as compared to three in 2001 and 2002, four in 2003, five in 2004, six cases in 2005,
14 in 2006, and 13 in 2007.
Conclusion:
This retrospective review of infections at our institution clearly delineates an increasing number of community-acquired MRSA hand infections. The plastic/hand
surgeon must be aware of the increased prevalence of this entity to adequately combat this organism and prevent prolonged hospital stays, expanded morbidity, and inflated treatment costs.
Radiographical Diagnosis of the Carpal Bone Fractures
Institution where the work was prepared: Showa University School of Medicine, Tokyo, Japan
Hirotsune Hirahara, MD; Souichirou Takigawa, MD; Katsunori Inagaki, MD; Kazutoshi Kubo, MD; Hideyo Miyaoka, MD; Showa University School of
Medicine
Carpal bone fractures are common, in the majority of cases this involves scaphoid, triquetrum or hamate. Sometimes fractures can be difficult to identify due to
complicated anatomical shape of the bones. Statistical analysis was performed on 252 retrospectively identified carpal bone fractures, that occurred in the past
16 years. 159 cases (63.1%) involved the scaphoid, 39 cases (15.5%) were triquetral fractures and 28 cases (11.1%) were hamate fractures. No trapezoid fractures were seen and the other carpal bones were only involved in less than 11% of cases. The authors feel that this is possibly due to the difficulty in diagnosing
these fractures. However, it is possible that these fractured were misdiagnosed more often. Tomography and CT scanning are often needed. Unfortunately these
constitute a greater radiation dose the patient of up to 10 times for tomography and even 250 times for CT. The cost of these techniques are also 2-3 times more
and are usually added to the cost of initial plain radiographs. The authors newly developed special radiographic techniques to better identify capitate and trapezoid fractures, using conventional radiographic equipment. When compared to the technique that is currently used we saw a great improvement in idetifying the
normal anatomy of these bones. This technique can easily be incorporated in standard clinical practice and should be used when there is a clinical suspicion for
a capitate or trapezoid fracture. This will result in an easier diagnosis of fractures that otherwise may have remained occult and will decrease the need for other,
more expensive, imaging techniques. This will have to be proven in further clinical research.
85
Sagittal Band Rupture in a Patient With an Anomalous Extensor Medii Proprius Tendon
Institution where the work was prepared: Geisinger Medical Center, Danville, PA, USA
John Thomas Riehl, MD; Joel Christian Klena, MD; Geisinger Medical Center
A cadaveric study of extensor medii proprius tendon incidence is presented along with a case report of sagittal band rupture involving an extensor medii proprius tendon. A review of the available literature is also presented.
A 22 year old male suffered an acute injury to the long finger of his dominant hand while playing volley-ball. The patient had persistent pain for approximately one-and-one-half years with undiagnosed ulnar extensor tendon subluxation. During operative reconstruction the patient was found to have an anomalous
slip of extensor tendon to the long finger. The tear of the sagittal band was between the anomalous tendon and the extensor digitorum communis slip. The
anomalous tendon was utilized as a radially-based sling to reconstruct the injured sagittal band with an excellent functional outcome.
Multidimensional Assessment of Chronic Neuropathic Pain
Institution where the work was prepared: Hand and Microsurgery Center of El Paso and UTEP, El Paso, TX, USA
Jose J. Monsivais, MD; Hand and Microsurgery Center of El Paso; Kris Robinson, PhD, FNP; University of Texas at El Paso; Diane B. Monsivais, PhD, RN;
The University of Texas at El Paso
Introduction:
Chronic pain affects 76.5 million people with an annual cost of $100 billion in health care, lost work productivity, and reduced income. Three out of four people with chronic pain are undertreated based on clinical practice guidelines. A frequent reason for this is the inadequate assessment of pain. Unidimensional
pain (typically a scale of 0-10) assessment is the most common in most practices. This unidimensional measure does not reflect the psychosocial impact of pain
or the impact on associated co-morbidities and function. Thus, the one time snapshot of assessment is notoriously inadequate and does not reflect the true impact
of chronic pain. Multidimensional assessment of pain: We suggest a three-part assessment. The first is a screening measure such as the Brief Pain Inventory
(BPI) that is widely available to clinicians at no cost. Not only does the BPI assess the severity of pain, it assesses the impact on psychosocial function and activities of daily life. The BPI is a highly reliable and valid instrument. Second, is the assessment of anxiety and depression of which there are many non-proprietary tools that can be used without cost, such as the Zung depression scale. Last, is the identification of co morbidities, such as diabetes and other
endocrinopathies, insomnia, deconditioning, etc., that influence and are influenced by chronic neuropathic pain.
Purpose:
The purpose of this presentation is to demonstrate the use of a multidimensional assessment of pain that identifies areas amenable to treatment and enhance
outcomes in terms of physical and psychosocial function, pain, and surgical results.
Methods:
An exploratory, correlational research design guided the study. Through convenience sampling, we recruited 92 patients seeking pain management treatment
for a neuropathic at a hand and microsurgery specialty clinic. Survey tools include the BPI, the SF-36vr2, a depression scale, and the unidimensional 1-10
pain scale. A statistician calculated descriptive statistics and conducted Pearson correlation coefficients. Post hoc analysis consisted of linear regression, ANOVA
and MANOVA.
Results:
The multidimensional assessment guided treatment that led to patient satisfaction and improved outcomes. We will present case studies emphasizing how the multidimensional assessment influenced treatment decisions and ultimately led to pain control and improved physical and psychosocial function.
Hand, Finger and Joint Comorbidities with Dupuytren’s Contracture in a Chart Confirmed Medical Claims Database Analysis
Institution where the work was prepared: United BioSource Corporation, Medford, MA, USA
Sheila M. Crean, BS, MPH1; Maxine Fisher, PhD2; Gregory Daniel, RPh, MS, MPH2; Dingwei Dai, PhD1; Matthew W. Reynolds, PhD1; (1)United BioSource
Corporation, (2)HealthCore Inc
Introduction:
Dupuytren’s contracture (DC) is a progressive nodular proliferation of fibrous tissue of the palmar fascia leading to contracture with permanent flexion of one
or more fingers. The purpose of this descriptive observational study is to evaluate DC concurrent with other conditions of the hand within a large managed care
medical claims database.
Methods:
A retrospective chart review was conducted to test the feasibility of diagnostic codes as markers for all true cases of DC in future database studies. With the first
728.6 ICD-9 diagnostic code as the index date, patients with 6 months of pre-index and at least 1 year post-index continuous eligibility were identified using longitudinal medical claims from HealthCore, dating from July 1, 2000 to April 30, 2006. Among patients with available provider information who were seen by
hand or orthopedic surgeons, 75 patients with at least one 728.6 ICD-9 diagnostic code for DC were selected. Charts corresponding to these dates were extracted for clinical documentation of DC or Dupuytren’s disease or palmar fibromatosis or contracture. Any other hand, finger and joint diagnoses within a 12 month
span of the initial 728.6 code date were also extracted.
Results:
Seventy one (94.6%) of the 728.6 identified patients had a chart documenting DC. Average age of patients with DC was 55.1 years (range 36-84) with a
1.63 M/F ratio. Of the documented DC patients, 20 (28%) experienced a total of 31 comorbid hand, finger or joint conditions. Overall, trigger finger and
carpal tunnel syndrome were the most common with a prevalence of 45% each; De Quervain’s disease, tenosynovitis, and ganglions were recorded in 10% of
patients each. DC patients with any comorbid hand, finger or joint disease were similar in age to DC patients without such involvement, (56.0 vs. 54.8 years).
DC women were twice as likely be coded for multiple hand, finger and joint comorbidites than DC men but this difference did not reach statistical significance.
Summary:
An ICD-9 diagnostic code of 728.6 predicts clinical cases of DC with excellent positive predictive yield of 94.6% when confirmed with a primary care chart.
This analysis shows that in this population of managed care patients, DC may exist with co-morbid hand, finger or joint conditions in about 1 in 4 patients.
Finally, although men are more likely to be diagnosed with DC, gender does not predict the presence of other concurrent hand, finger or joint conditions.
86
Ganglion cysts in chindren: Experience at the Hospital for Sick Children
Institution where the work was prepared: Hospital for Sick Children, Toronto, ON, Canada
M. Amir Mrad, MBBS; Tatiana Cypel, MD; Ronald Zuker; University of Toronto
Purpose:
Bumps and lumps are common among children. However, one bump that shouldn’t be overlooked is called a ganglion cyst. A ganglion or a synovial cysts is
a muscinous filled cyst which is usually found adjacent to joint capsule or tendon sheath. A common problem in adults, ganglion cysts are much less common
in children. In this study, we aimed to detect the epidemiology, etiological factors, symptomatology, treatment and outcome of patients diagnosed with a ganglion cyst at The Hospital for Sick Children.
Methods:
Records from the Pathology Department at The Hospital for Sick Children were searched for all cases of ganglion cyst operated between January 2000 and
December 2007.
Results:
Thirty-four patients were diagnosed with ganglion cysts. The mean age was 15.7 years, ranging from 5 months to 17 year old. Male:female ratio was 1:1.
Solid lump was the initial presentation of the ganglion in 36% of the cases. Pain was the most common symptom to indicate surgical removal. Only 11.4% of
the patients reported previous trauma history. In 70% of the cases the diagnosis was done clinically and 61% of the patients were affected on the right side of
the body. The most common sites of occurrence were volar wrist (25.7%), dorsal wrist (22.8%) and the volar aspect of the base of ring (17.1%). Surgical excision was the treatment of choice for 94.2 % of patients with symptomatic lesions. Only one patient (2.8%) presented with recurrence in this series.
Conclusions:
Ganglion cysts are not uncommon in children. Among all symptoms that ganglions can present with, pain was the most common symptom that indicated surgery. Surgical removal was the most effective treatment for symptomatic patients, with a very low rate of recurrence.
Operative Treatment Rates for Hand Pathologies based on Diagnostic Indications
and Referral Patterns
Institution where the work was prepared: Harvard Medical School / Beth Israel Deaconess Medical Center, Boston, MA, USA
Melvin Chugh Makhni, BS1; Henry Horton1; Eric Makhni1; Christine Y. Ahn2; Charles Day1; (1)Harvard Medical School / Beth Israel Deaconness Medical
Center, (2)Na
Background:
This study looks at the distribution of hand and wrist pathologies as well as the referral patterns to orthopaedic surgeons to see how these factors correlate with
likelihood of operative management.
Methods:
We performed a retrospective chart review study of 1916 consecutive adult hand and wrist cases in the orthopaedic hand clinic at our academic tertiary care
medical center, from January 2005 to January 2007. Over 300,000 data points were analyzed for the 1916 cases; each individual diagnosis pertaining to
the hand or wrist was assigned as a unique case. Cases were designated as traumatic (trauma <21 days prior), acute non-traumatic (symptomatic <90 days),
or chronic (>90 days).
Results:
Traumatic pathologies represented 10% of cases, acute cases comprised 32%, and 58% were chronic. 41% of traumatic cases underwent surgical management as compared to 35% of chronic cases (p=.04); acute pathologies were treated with surgery 29% of the time, significantly less than chronic cases (p=.03).
Traumatic cases underwent surgery immediately after first recommended significantly more commonly than acute or chronic cases (p=.006, p=.009). Overall,
acute and chronic surgeries were performed when recommended at similar rates. However, 95% of acute strains and fractures were operated upon when recommended as compared to only 75% of chronic cases (p=.05), while a trend regarding neurological symptoms showed 89% of patients with chronic symptoms underwent surgery when recommended versus 76% of patients with acute symptoms (p=.08). -64% of the 1916 diagnoses were from females. Cases
involving females resulted in surgery 32% of the time, as compared to 39% of male cases (p=.004). -Cases were referred by primary care physicians 68% of
the time and from specialists 8% of the time. 13% came from the ER, while the rest were from other referral sources. Cases referred by specialists resulted in
surgery 41% of the time, as compared to only 32% of cases from primary care physicians (p=.04). 96% of cases from the emergency room resulted in surgery
immediately upon recommendation, as compared to 89% of cases referred from primary care physicians (p=.02).
Discussion:
A better understanding of operative management rates will allow orthopaedic surgeons to convey to patients the likelihoods that cases will result in surgery. Increased education of primary care physicians about musculoskeletal differentials and conservative treatment options may enhance the utility of orthopaedic
surgeons to patients.
87
The Lateral Approach to PIPJ Ascension Arthroplasty
Institution where the work was prepared: University of Manitoba , Winnipeg MB, Canada
Ghazi Ayedh Althubaiti, MD; Kenneth Murray; Mehrdad Golian; University of Manitoba
Introduction:
The dorsal approach is currently the most widely used approach for surface replacement arthroplasty of PIP joint. One of the major disadvantages of the dorsal
approach is the need to divide or detach the central slip of the extensor tendon, which weakens extension and delays physiotherapy.
Purpose:
Report our initial results of using the lateral approach as an alternative approach in 5 patients with 6 PIP arthroplasties.
Method:
A retrospective chart review of all of our patients who had PIP joint Ascension arthroplasty who were operated on using lateral approach between 2004 and 2008.
Results:
Among seven patients who underwent Ascension PIP aprthroplasties, five patients were operated on using the lateral approach. One patient had 2 adjacent
joints simultaneously replaced. All of our patients were started on immediate ROM from first post-operative day. The average arc of motion was 49 degrees
before surgery and 78 degrees after surgery with the average gain of 29 degrees to the arc of motion 6 weeks after surgery. Pain decreased in all patients
after surgery. Two patients had joint subluxation, one of them had 2 adjacent fingers PIPJ arthroplasty that made physiotherapy and buddy taping difficult
which affected the joint stability.
Conclusion:
Although this is a small study, but it seems to show that lateral approach for PIPJ Ascension arthroplasty may offer the advantage of preserving the extensor
tendon and starting early ROM that improves the final outcome. One of the learned lessons from this study is not to “arthroplasty” two adjacent digit hence it
will affect the lateral stability of both joints and make physiotherapy and buddy taping difficult.
Learning objectives:
The audience will be introduced to the lateral approach PIPJ Ascension arthroplasty. Never use this approach to simultaneously treat two adjacent digits.
Carpal Tunnel Syndrome: Factors Influencing Permanent Nerve Damage
Institution where the work was prepared: The Hand Center, Houston, TX, USA
Michael Fitzmaurice, MD1; Michael Brown2; Randolph Lopez, MD2; Mark Khorsandi2; Andrew Lee2; Douglas Harper2; Nur Nurbhai2; P Stephen
Mahoney1; (1)Brown Hand Center, (2)The Hand Center
12,171 patients with carpal tunnel syndrome (CTS) were studied over twelve-years to determine the treatment factors that contribute to permanent nerve damage (PND). The diagnosis was established electrodiagnostically and categorized into mild, moderate, severe or profound. Various treatment modalities were
studied including the Brown procedure endoscopic carpal tunnel release only, as well as various non-operative interventions: Non-steroidal anti-inflammatory
drugs (NSAIDS), NSAIDS and oral steroids, and injected steroids. The incidence of resultant permanent nerve damage was further categorized as to duration
of CTS subsequent to definitive electrodiagnostic confirmation of CTS. Patients with more severe CTS as well as patients with a longer duration of CTS regardless of severity had a higher incidence of PND. Those patients who underwent non-operative treatment had longer durations of symptoms and higher rates of
PND. Treatment with injectable steroids prior to definitive surgical treatment resulted in a significantly higher incidence of PND.
Quantifiying Upper Extremity Replant Patients Quality of Life Using Utility Theory
Institution where the work was prepared: University of Montreal & McGill University, Montreal, QC, Canada
Oren Tessler, MD, MBA1; Genevieve Landes, MD2; Jean-Paul Brutus, MD3; Patrick Harris, MD2; H. Bruce Williams, MD1; Andreas Nikolis2; (1)McGill
University, (2)Université de Montréal, Hôpital Notre-Dame, (3)Centre Hospitalier de l Université de Montréal
Purpose:
Improvements in microsurgical technique have dramatically increased replant survival rates to over 90% since the initial report of upper extremity replantation
in 1964. Tissue survival however, does not always correlate with useful extremity function. Measuring functional outcomes has been historically difficult because
of the heterogeneity of mechanisms involved in the injury, patient factors, and associated injuries. Research in this field has thus attempted to develop increasingly specific evidence-based surgical indications. Utility theory represents a group of economic game theory-derived Health Related Quality of life assessment
tools designed to help quantify uncertainty in medicine. It has been used extensively in medical decision-making over the past 40 years and has proven to be
valid, reliable, and responsive for a large number of clinical conditions. This study is a novel attempt to examine the validity of utility theory measures as it
applies to upper extremity replant patients.
Methods:
Patients treated by the Quebec Replant Center were evaluated at a point of one year or greater from their final reconstructive procedure. Using the EuroQol,
Visual Analog Scale (VAS), Time Trade-Off (TTO), and Standard Gamble (SG) questionnaires, we compare scores to the previously validated hypothetical clinical marker states of monocular and binocular blindness and to traditional replant outcome measures, including objective (ROM, sensibility, etc.), subjective
(satisfaction, pain, etc..), and DASH assessments.
Results:
We report that utility theory can represent a highly reliable, valid, and responsive standardized tool that can be used universally in assessing replantation results.
Discussion:
It is our belief that utility theory can be developed as a simple and unified score for the multitude of surrogate measures in use to evaluate replantation outcomes.
Learning Objectives:
1. Participants will be able to identify patients who will likely benefit from surgical replantation.
2. Participants will be able to communicate realistic outcome expectations with patients.
3. Participants will be able to develop more specific treatment algorithms for upper extremity replant programs.
88
Lunotriquetral Instability: Treatment via Dorsal Capsulodesis
Institution where the work was prepared: University of California, Davis, Sacramento, CA, USA
Robert R. Slater, MD; University of California, Davis
Introduction:
Instability of the lunotriquetral (LT) joint is one source of ulnar wrist pain, and symptoms can be disabling. Traditional treatment options have focused either on indirect
management via ulnar shortening osteotomies in an effort to tighten all ulnar-sided soft tissue structures or on arthrodesis of the LT joint. Ideally, it would be better to treat
the pathology directly while still preserving intercarpal motion. A new technique to achieve that goal is described herein.
Methods:
The wrist is approached dorsally and the dorsal intercarpal ligament (DICL) is dissected. A strip of the ligament is harvested from its distal, radial insertion, rotated on its
origin off the dorsal triquetrum and then anchored to the lunate. Pin fixation maintains the intercarpal alignment post-operatively while the wrist is casted. Supervised hand
therapy follows pin and cast removal.
Illustrative Case:
A male custodian presented with post-traumatic ulnar-sided wrist pain. Clunking occurred as the injured wrist moved from radial to ulnar deviation. Grip strength was
75% and ROM was 90% vs. the opposite wrist. Fluoroscopy showed LT instability. At surgery, the LT disruption was confirmed arthroscopically. Open reconstruction was
performed as described. The cast and K-wires were removed at 8 weeks. Outcome was excellent: return to full activities and labor without pain.
Results:
Excellent results were obtained as evidenced by elimination of pain and return of grip strength to nearly match the uninjured side. ROM remained slightly decreased, particularly in flexion, but did not cause functional limitations.
Discussion:
The treatment of flexible deformities of the wrist due to intercarpal ligament injuries remains controversial. Tenodeses and arthrodeses have been utilized in the past for LT instability but with problems due to stiffness and nonunion. Ulnar shortening has different complications and does not attack the pathology directly. The technique described here was
developed in an effort to solve these challenging dilemmas. Favorable results suggest the technique is a valid option that warrants consideration and further investigation.
Plate Arthrodesis of the Proximal Interphalangeal Joint
Institution where the work was prepared: Medical College of Georgia, Augusta, GA, USA
Samuel Schroerlucke, MD; Simeon Marcus Fulcher, MD; Clay Spitler, MD; Medical College of Georgia
Hypothesis:
Several fixation techniques have been described for proximal interphalangeal joint (PIP) arthrodesis. The literature is sparse with respect to plating and suggests that it has
inferior fusion rates, is technically difficult, frequently requires hardware removal and should be reserved only for extensive PIP joint trauma. A review of all plate arthrodeses of the PIP joint at our institution reveal an excellent fusion rate, no need for future hardware removal, and a technically simple and reproducible surgical technique for
all conditions requiring a PIP fusion.
Methods:
Between November 2001 and June 2007, 21 patients, totaling 27 fingers, had PIP arthrodeses using plating techniques by a single surgeon. The indications were trauma with open fractures in 8 fingers, contractures of the PIP joint in 7 fingers, posttraumatic arthritis in 8 fingers, degenerative or inflammatory arthritis in 3 fingers, and
salvage of a failed tension band wire arthrodesis in one patient. The technique was performed by the same surgeon (SMF) through a dorsal approach using mini-plates
and screws (1.3, 1.5 or 2.0 mm). Patients were analyzed for preoperative diagnosis, age, time to fusion, need for subsequent procedures, and type and size of plate
used.
Results:
Twenty-six of twenty-seven (96%) PIP joints achieved fusion with an average time to union of fifty-six days. Average age of the patients was 47. The most common plate
used was a 5 hole 2.0 mm plate, however, three 1.3 mm T-plates and four 6 hole 1.5 mm plates were used. The single nonunion was an acute open fracture which developed an infection requiring early hardware removal. No other finger required hardware removal.
Summary:
The literature suggests that plating for PIP arthrodesis as compared to other methods has an inferior fusion rate, the necessity for frequent plate removal, and states that
the procedure itself is technically demanding.
· We present a 96% fusion rate (26/27) of proximal interphalangeal joints treated by plate arthrodesis.
· No patient required hardware removal for prominent hardware.
· Surgical technique is technically simple and reproducible.
Forearm Compartment Syndrome. A 5-Year Review
Institution where the work was prepared: University of Texas- Houston / Health Science Center, Houston, TX, USA
Erik Marques, MD; University of Texas - Houston
Background:
Appropriate and timely treatment of upper extremity compartment syndrome is dependent on accurate diagnosis of the underlying process, including both common and infrequent
etiologies. If treatment is delayed, compartment syndrome may result in tissue loss and permanent functional impairment.
Methods:
A retrospective chart review was conducted on all cases of forearm compartment syndrome (CS) managed by a single plastic surgeon over a 5-year period (12/2002
to 12/2007) at an academic medical center.
Results:
Fourteen extremities in eleven patients (9 male, 2 female) were diagnosed with forearm CS preoperatively. Average age was 37.5 years (range 11 months to 57 years). The most
common cause was direct trauma to the affected extremity (7/14; 5 penetrating, 2 crush injuries). In the remaining extremities, the etiologies included: advanced infection; avulsion
amputation of index finger at PIP joint; infiltrated antecubital intravenous line during blood transfusion (Figure 1); radial artery punctures for arterial blood gas in an anti-coagulated
patient (bilateral upper extremity); and after prolonged CPR in an obtunded, ventilated patient on pressor support (bilateral upper extremity). All affected extremities underwent emergent fasciotomy. Treatment was delayed (>6 hours) in 3 patients (4 extremities), of which 2 patients (3 extremities) were unconscious; both patients developed Volkman’s contractures.
Discussion:
This case series highlights several important points regarding forearm CS: (1) Although forearm compartment syndrome is frequently caused by direct trauma, less common etiologies must be considered. (2) Prompt diagnosis and timely treatment are required for salvage of limb function (3) A high index of suspicion is necessary when patients are anticoagulated and/or unconscious (ie. sedated, obtunded, ventilated). (4) We must strive to educate our referring physicians about the diagnosis, treatment, and multiple potential
etiologies of upper extremity compartment syndrome.
89
The Rise of Methicillin Resistant Staphylococcus Aureus in Surgically Treated Hand Infections
Friedrich JB, Division of Plastic Surgery, University of Washington, Seattle, WA and Imahara SD, Division of Plastic Surgery, University of Washington,
Seattle, WA
Background:
Hand surgeons are commonly asked to treat bacterial infections of the hand. Recently, an alarming increase in the incidence of community-acquired methicillin-resistant Staphylococcus aureus (ca-MRSA) infections has been observed among all soft-tissues, including the hand. In addition to the inherent morbidity
of hand infections, this pathogen poses further treatment and prevention challenges. Prior studies of ca-MRSA infections of the hand, specifically regarding risk
factors, are small in number. The purpose of this study is to determine the change in incidence of surgically-treated ca-MRSA hand infections, and to identify
risk factors associated with this pathogen.
Methods:
A retrospective review of a county hospital discharge database was performed to examine all surgically-treated hand infections over a 10-year time period
(1997-2007). Examined data included demographic information, social factors, nature and location of infection, surgical management, and postoperative
antibiotics. The yearly incidence of ca-MRSA was calculated. Independent variables associated with ca-MRSA were determined, and were then analyzed via
logistic regression to determine risk factors for ca-MRSA hand infections.
Results:
There were 159 surgically-treated hand infections during the study period. Forty-eight (30%) were culture-positive for ca-MRSA. Mean age was 40 years, mean
inpatient length of stay was 4.9 days, and 72% of patients were male. The yearly incidence of ca-MRSA increased over the study period (p<0.001). Variables
independently associated with ca-MRSA were IV drug use (p=0.002), and second admission for a separate hand infection (p=0.005). The following were not
associated with ca-MRSA: age, gender, homelessness, incarceration, other co-morbidities including HIV and diabetes mellitus, and infection type/location.
Binary logistic regression identified increasing year of infection (OR 1.39, 95% CI 1.18-1.63) and IV drug use (OR 3.91, 95% CI 1.67-9.13) as significant risk
factors for ca-MRSA hand infections.
Conclusions:
Like ca-MRSA infections of other soft tissues, the incidence of surgically treated ca-MRSA hand infections increased with time in the last decade. Additionally,
more recent infection and injection drug use were associated with an increased likelihood of ca-MRSA. Factors previously thought to be associated with this
pathogen, such as homelessness, incarceration, and other co-morbidities were not found to be risks in this study. Future prospective studies are needed to further define risk factors for, and optimal treatment of ca-MRSA hand infections.
90
ASPN Scientific Paper Session A
Impact of C7 Transection on the Upper Limb: Quantification of Motor Function in a Rat Model
Huan Wang, MD, PhD; Anthony J. Windebank; Robert J. Spinner; Mayo Clinic
Introduction:
Contralateral C7 transfer has been used clinically for over 20 years. With the increased interest in studies of transfer effectiveness, reconstructive strategy, posttransfer co-contraction and brain plasticity, the need for an animal model also arises. Rather than the conventional electrophysiologic, histomorphometric and
biomechanic evaluation modalities, quantitative functional/behavioral evaluation will be crucial in applying this kind of model.
Methods:
In the current study Sprague Dawley rats, the brachial plexus of which resembles the human brachial plexus, were used as animal models. C7 transection was
created in 6 rats. The impact of C7 transection on the donor limb function, including strength, movement and coordination, was evaluated. Muscle strength
(power, grams) was measured by grasping task. The active range of motion (angle, degrees) of the elbow, wrist and metacarpophalangeal joints was quantified by computerized video motion analysis. Anti-resistance coordinated movement (speed, seconds) was assessed by vertical rope climb test. These tests were
carried out before the surgery and at 2, 4, 6, 8, 10, 14, 21 and 28 days after C7 transection. Repeated measures one-way ANOVA was applied for statistic analysis. When overall P value was less than 0.05, Dunnett's multiple comparison post test was done to compare postoperative values with pre-operative
baseline values.
Results:
Immediately after C7 transection, grip strength dropped from 378.50 ± 20.55 g to 297.77 ± 15.04 g. Active elbow extension was impaired as shown by a
significant decrease in elbow extension angle. There was obviously reduced speed of vertical rope climb. Elbow flexion, wrist flexion/extension, MP joint flexion/extension were not impaired. Fast recovery of motor function was observed thereafter. Grip strength returned to baseline value at postoperative day 4.
Range of active elbow extension returned to normal at postoperative day 8. Speed of rope climb also returned to baseline value at postoperative day 8.
Conclusions:
The range of motion and muscle strength of the upper limb in rats can be quantitatively measured. This opens a venue for studies that simulate clinical situations. Application of these functional evaluation modalities in a C7 transection model in rats confirmed that transection of C7 only causes temporary functional deficit to the donor limb. These results obtained in this animal model mimic those seen in humans who undergo contralateral C7 harvest.
Anatomic Study of Roos' Type 3 Band and its Relationship to the Lower Roots of the Brachial Plexus
Julia Spears, MD1; Salim C. Saba, MD1; David C. Kim, MD, FACS2; Amitabha Mitra, MD1; Carson Schneck, MD, PhD3; (1)Drexel University College of
Medicine, (2)Temple University Hospital, (3)Temple University
Ulnar nerve compression is one of the commonest clinical presentations of thoracic outlet syndrome (TOS). Vagueness of symptoms, lack of objective diagnostic studies, and complexity of the anatomy, make surgical intervention challenging. It is universally agreed that TOS is under-diagnosed due to lack of proper
diagnostic tools. A plethora of anatomic variations including cervical ribs, first rib abnormalities and pectoralis minor bands have been implicated in the etiology of TOS. Roos' identification and classification of scalene muscle and fibrous bands has added an additional dimension to understanding of the etiology
and subsequent treatment of TOS. The Roos Type 3 band is the most commonly encountered first rib band during surgical exploration. Currently however, its
importance in clinical symptoms is not fully understood.
In order to further delineate the anatomical significance of the Roos Type 3 band, we undertook the dissection of 100 cadaveric first ribs on 70 cadavers. The
Type 3 band was identified in 35 ribs, and was encountered bilaterally in 6 cadavers. Contrary to prior studies, it was found that the Type 3 band traveled
over the T1 nerve root forming a tunnel which we believe could lead to compression. We also confirmed that this band originates as a thickening of the pleura. The precise anatomic knowledge of this band may lead to development of a simpler and less invasive surgical approach, possibly paving the way for endoscopic intervention. We are presently completing further correlation with magnetic resonance imaging studies on patients with TOS.
91
Retroperitoneal Femoral Nerve Reconstruction in the Paediatric Population
Institution where the work was prepared: The Hospital for Sick Children and the University of Toronto, Toronto, ON, Canada
Howard M. Clarke, MD, PhD, FRCS(C); Kim Tsoi; Bart M. Stubenitsky; Christine G. Curtis; Justin T. Gerstle; Hospital for Sick Children
Purpose:
Lumbar plexus and retroperitoneal femoral nerve lesions in children are rare. Such injuries may result in severe functional impairment of ambulation and standing and sensory impairment over the anterior-medial thigh, the medial aspect of the leg and the arch of the foot. Treatment is challenging due to the complex
anatomy and the difficulty of obtaining surgical access. Often a conservative approach is chosen, believing that the surgical risks outweigh potential benefits.
Our experience derived from the surgical treatment of three cases is reported.
Methods:
For the reconstructive surgery, patients were placed in a modified lateral decubitus position. Making use of a retroperitoneal exposure provided by the paediatric general surgeon, the nerve stumps were identified proximally and distally and specimens were taken for histological quality assessment. After adequate
nerve resection, the hip was placed in extension and strands of sural nerve were interposed as grafts between the stumps in a tension-free manner. The neurorrhaphies were completed with fibrin glue and without sutures.
Patient at
Surgery
Nature of retroperitoneal
Nerve lesion
Repaired nerve
and nerve gap
Timing of sural
nerve grafting
A
15 yr male
Severe crush injury with
open book pelvic fracture
Right femoral nerve
11-14cm
6 months post trauma
B
16 yr male
Radical resection malignant
Left femoral nerve 12cm 2 months post ablation
schwannoma at L3 root level
C
1 yr female
Cyclic neutropenia with
cecal perforation and
necrotizing faciitis
Age at
Follow-up
Post Nerve Graft
A
20 yr
4.5 years
B
20 yr
C
3 yr
Right femoral nerve 10cm 4 months post excision
Preoperative Knee
extension
Motor
function
Preoperative Knee
extension
MRC
AMS
MRC
AMS
0/5
0/7
5/5
7/7
3 years
0/5
0/7
2+/5
6/7
able to jog,
reciprocal stair
climbing, participates in sports
2 years
0/5
0/7
4/5
7/7
stairs one at a time,
running slowly
without a limp
walking without aids,
reciprocal stair
climbing, running
short distances
All patients were able to walk without aids at final follow-up. Sensory function improved in all patients with substantial resolution of preoperative dysesthesia in patient A.
Conclusions:
Retroperitoneal femoral nerve disruption in children is a rare but devastating lesion. Appropriate surgical access to the retroperitoneal space is a prerequisite
for lumbar plexus reconstruction and mandates a team approach. In this series, all patients regained excellent function following reconstruction. The surgical
treatment of these rare but devastating lesions in childhood proved highly rewarding.
The Case for Neuroma Resection: Recovery of Elbow Flexion after Nerve Grafting
in Obstetrical Brachial Plexus Palsy
Institution where the work was prepared: Children's Healthcare of Atlanta, Atlanta, GA, USA
Thomas J. Moore, MD; Emory University; Ann R. Schwentker, MD; Children's Healthcare of Atlanta
Fifty-one patients underwent primary surgical reconstruction of obstetric brachial plexus injury by a single surgeon over a three year period. Indications for
brachial plexus repair include a Toronto Score less than or equal to 3.5 at three months of age or failure to pass the Cookie Test at nine months of age. Surgery
consisted of resection of anatomically abnormal brachial plexus, including conducting neuromata-in-continuity when present, and interpositional nerve grafting. Elbow flexion was assessed using the Active Movement Rating Scale (AMRS) preoperatively and at 3, 6, 9, and 12 months postoperatively. 36 patients
had at least 12 months of follow-up data available and were included in analysis. Of these, 18 had clinically evident preoperative elbow flexion or an AMRS
? 2 (+flexion), and 18 did not (–flexion). At 3 months, 50% of +flexion patients had recovered some flexion compared to 6% in the –flexion group. Despite
resection of the conducting neuroma in the +flexion patients, average elbow flexion by 9 months was above pre-operative measurements. At 12 months, 100%
of +flexion patients had recovered clinically evident elbow flexion, versus 82% of the –flexion patients. Patients with preoperative elbow flexion had better
elbow flexion across all time points (p<0.001) and a faster rate of recovery (p=0.001), although all patients improved over time (p<0.001). Recovery of elbow
flexion after brachial plexus reconstruction is faster when preoperative elbow flexion is present.
Table 1- Two groups of patients are shown, those with active flexion present before surgery (+flexion) and those who had no active flexion before surgery (–flexion). The number of patients with active elbow flexion (?2 on AMRS) at 3 month intervals after primary brachial plexus reconstructive surgery is shown.
3 months
6 months
9 months
1 year
+Flexion Group
9/18 (50%)
16/18 (95%)
14/14 (100%)
17/17 (100%)
–Flexion Group
1/18 (6%)
2/18 (11%)
7/15 (47%)
14/17 (82%)
92
Nerve Transfers to Reanimate Elbow Flexion in Obstetric Brachial Plexus Lesions
Institution where the work was prepared: Leiden University Medical Center, Leiden, Netherlands
Willem Pondaag, MD; Martijn J.A. Malessy, PhD; Leiden University Medical Center
Introduction
In obstetric brachial plexus lesions with avulsion injury, nerve grafting is not possible due to the lack of a proximal stump as lead-out. For reanimation of elbow
flexion good results have been described as well from intercostal to musculocutaneous nerve transfer (ic-mc) as from transfer of the medial pectoral nerves (pecmc). In the present study the success of both these techniques in a single institution were studied.
Patients
We analyzed 30 consecutive patients from our institution (1995-2005) in whom nerve transfers for biceps reanimation had been applied. From 1995-2000
only ic-mc transfers were performed, from 2001-2005 both techniques were applied. In the ic-mc patients, the lesions tended to be more severe: 8 patients
had a flail arm. The pec-mc was usually applied in case of an isolated C5/C6 avulsion, which often resulted from breech delivery. Alternatively, the pec-mc
transfer was used when shoulder innervation was relatively intact but recovery of biceps muscle had not occurred.
Surgical Technique
In all but one ic-mc patients three intercostal nerves were coaptated directly to the musculocutaneous nerve; once a 1 cm graft proved necessary. In the patients
with pec-mc transfer, in half of the patients the musculocutanous nerve was significantly bigger in diameter than the pectoral nerves, so the musculocutaneous
nerve was sectioned only partially, leaving half of the nerve intact.
Results
Useful elbowflexion > MRC 3 was achieved in 13/16 (81%) in the ic-mc group and in 13/14 (93%) of patients in the pec-mc group after a mean follow-up
of 40 months. In the ic-mc group once secondary surgery was performed (Steindler flexor-plasty). No adverse effects were noted in both groups, especially no
rib cage deformity.
Discussion
Both techniques had a good success rate; explanations for the failures will be discussed in more detail. Generally speaking, a pec-mc transfer is indicated when
the lesion is limited to mainly C5 and C6. In case of a more severe lesion and more spinal nerves are damaged, an ic-mc transfer is favoured.
The Evaluation of Sensory Function for the Patients of Suprascapular Nerve Palsy
Institution where the work was prepared: Dept. of Orthop. Surg., School of Medicine, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, Japan
Hiroyasu Ikegami, MD, PhD; Kiyohisa Ogawa, MD, PhD; Noriaki Nakamichi, MD; Toshiyasu Nakamura, MD, PhD; Kazuki Sato, MD, PhD; Masato
Okazaki, MD; Yoshiaki Toyama, MD, PhD; Keio University
[Purpose] Ajmani and Horiguchi reported a cutaneous branch of the suprascapular nerve supplying the proximal-lateral one-third of the arm. There is, however, no
paper that reports the relationships between clinical symptoms and sensory disturbance in the patients of suprascapular nerve palsy. We report the usefulness of the
evaluation of sensory function for suprascapular nerve palsy. [Patients and Methods] We treated 66 patients of suprascapular nerve palsy from 1985 to 2006. To
study the usefulness of evaluating sensory function, we investigate the clinical progress and the results of the sensory disturbance in 13 cases of suprascapuar nerve
palsy in which the sensory tests were done more than two times. As the sensory function, we evaluated vibration thresholds, pain, light touch, and the sensation of
heat and cold. [Results] In all the cases, we found atrophy of infraspinatus muscle, dullness around the shoulder joint, tenderness at the entrapment point. Five cases
had ganglion treated by puncture. We excised ganglion in two cases. We diagnosed 6 cases without ganglion cysts as neuralgic amyotrophy from the characteristic clinical progress and electromyography. We did decompression of the suprascapular nerve by a trapezius-splitting surgical approach. In the tests for evaluating
sensory function, there are no cases with abnormal vibration thresholds. There are 11 cases with hypalgesia and hypothermesthesia in the region of posterior axillary pouch and 9 cases with hypaesthesia in the same area (Fig. 1). [Discussion] The evaluation of sensory function for the patients of suprascapular nerve palsy is
useful for follow-up of this palsy, because this is non-invasive, inexpensive, and sensitive comparing with MRI and electromyography.
Treatment of the Divided Spinal Accessory Nerve and Tendon Transfers
Harilaos T. Sakellarides, MD; Boston University School of Medicine
Purpose:
To show that a very serious injury can be improved by performing the appropriate operation.
Methods:
Ten cases with paralysis of the trapezius muscle have been treated in the past 25 years. Most cases were the result of accidental injuries. Half were of iatrogenic origin, namely paralysis followed the removal of small lipomas from the neck area. Of the six men and four women, the right side was involved six times,
the left four times. All patients were handicapped in using their extremities, causing marked weakness in abduction, with difficulty performing activities such as
fishing, tennis, golf and other sports as well as simple tasks like combing their hair, putting hand behind neck and elevating the arm. The operation consisted
of transferring the insertion of the levator scapulae with fascial sling through the acromion. The fascial sling was also used to anchor the spinal border of the
scapula to the spinous processes of the upper two dorsal vertebrae. The lateral transfer of the rhomboid muscle in a double-breated fashion was added to this
procedure.
Results:
Excellent and Good 75%; Fair 25%. In this later group all patients demonstrated much improvement compared with the pre-operative status.
Conclusions:
This method has been found to be satisfactory for correcting paralysis of the trapezius.
93
Topographic Distribution of Sensory and Motor Axons in the Human Brachial Plexus:
A First Step Toward Function-Specific Targeted Reinnervation
Institution where the work was prepared: Northwestern University Feinberg School of Medicine, Chicago, IL, USA
[authors]Jason H. Ko, MD1; Mauricio De la Garza, MD1; Peter S. Kim, MD1; Todd A. Kuiken, MD, PhD2; Gregory A. Dumanian, MD1; (1)Northwestern University
Feinberg School of Medicine, (2)Rehabilitation Institute of Chicago
Background: Targeted reinnervation is an effective strategy to achieve a functioning neural-machine interface that allows upper extremity amputees to voluntarily control myoelectric prostheses. Refinement of the operative technique may lead to improved results. To our knowledge, the topographic distribution of motor and sensory axons within the peripheral nerves as they originate from the brachial plexus has not been described, as there has previously not been a need to understand this microanatomy. Determining this topography will potentially allow for motor- and sensory-specific neurotizations during targeted reinnervation. Methods: Through the Gift of Hope Organ and Tissue Donor Network,
we obtained bilateral brachial plexus nerves from fresh human cadavers that were refrigerated--and never frozen--for less than 15 hours after death. Cadavers ranged in age
from 54 to 72 years with a mean refrigeration time of 10.6 hours (range 8-15 hours). Immunohistochemistry for choline acetyltransferase (ChAT) was used to label motor axons
in the musculocutaneous, median, radial, and ulnar nerves just distal to the brachial plexus. Results: Choline acetyltransferase selectively stains motor axons on cross sections of
the upper extremity nerves as they originate from the brachial plexus (Figure). Topographic patterns of motor axons display potential to divide the nerves based on their fascicular anatomy to allow for increased number and selectivity of nerve transfers for targeted reinnervation. Immunofluorescent sensory stains—such as parvalbumin (PV) for myelinated proprioceptive axons—are currently being explored as adjuncts to the motor axon labeling. Conclusion: The use of fresh cadavers prior to decay of nerve tissue has allowed
us to better understand the topographic distribution of motor and sensory axons within nerves as they originate from the brachial plexus. This information will potentially allow
for more precise, function-specific targeted reinnervation to control a new generation of myoelectric prostheses with sensory feedback.
Evaluation of Pain Measures Used by Peripheral Nerve Surgeons
Christine B. Novak, PT, MS, PhD(c)1; Dimitri J. Anastakis1; Dorcas E. Beaton1; Joel Katz, PhD2; (1)University of Toronto, (2)University of Toronto, York University
In patients with a peripheral nerve injury, neuropathic pain can be a significant impairment and negatively affect outcome. Many outcome studies following nerve injury
present motor and sensory functional outcomes but do not report on neuropathic pain or the psychosocial factors that may be associated with pain.
Purpose:
The purpose of this study was to evaluate the opinions of peripheral nerve surgeons regarding pain assessment and treatment in patients following nerve injury.
Methods:
Surgeons with expertise in the treatment of patients with upper extremity peripheral nerve injuries and members of an international peripheral nerve society were included in this
study. Following approval by our institutional Research Ethics Board, an introductory letter and electronic survey were sent by email to the members. Non-respondents were sent by
email two subsequent reminders. The surgeons who were in active surgical practice and had an active email address were invited to participate in the study (n = 133). There were
59 surgeons who completed to the survey (44% response rate).
Results:
There were 49 men and 10 women (mean age 49 years and mean years in practice 16) and the majority were from plastic surgery (n=37), orthopedic (n=12) or neurosurgery (n=8). In patients referred for motor or sensory dysfunction, 31 surgeons (52%) indicated that they always formally assess pain and in those patients referred
for pain, 44 surgeons (75%) quantitatively assess pain using a verbal scale (n=24), verbal numeric scale (n=36), visual analog scale (n=14) or pain questionnaire (n=7).
When asked “When neuropathic pain becomes chronic?”, 6 months was the most frequent response (range 3 days to 1 year). The most frequent factors that were considered very important in the development of chronic neuropathic pain included psychosocial factors (64%), mechanism of injury (59%), involvement of workers' compensation or litigation (54%) and iatrogenic injury from previous surgery (48%). In patients more than 6 months following nerve injury, the following factors were identified
as frequently seen by the surgeons: cold sensitivity (54%), paraesthesia/numbness (41%), decreased motor function (42%), emotional/psychological distress (17%), fear
of returning to work (22%), neuropathic pain (20%) and fear of using extremity (22%).
Conclusion:
Only 52% of peripheral nerve surgeons evaluate pain in patients referred for motor/sensory dysfunction. Pain assessment most frequently includes a verbal patient
response and very few peripheral nerve surgeons use a validated questionnaire. Patient related factors were most frequently considered important in the development of
chronic neuropathic pain.
Determining Cortical and Functional Deficits following Partial Transected Nerve
Donation in a Rat Model using fMRI
Seth Jones, MD; Rupeng Li; James Hyde; Hani Matloub; Ji-Geng Yan; Medical College of Wisconsin
The use of a partial transected donor nerve for peripheral nerve reconstruction has recently become a new option for peripheral nerve surgeons. Determining the residual deficits after using a portion of a donor nerve has increasingly become the primary question to be answered. We have developed and reported on a functional MRI
protocol in a rat model whereby we directly stimulate a peripheral nerve and examine the cortical BOLD signal after the stimulation. We have done this for each of the
four major nerves of the upper extremity (median, ulnar, musculocutaneous, radial). Using these as our baseline we intend to compare these cortical BOLD signals with
the BOLD signals of the nerve after transecting 50% of the nerve. We will compliment our study with a grip strength test. METHODS: 18 SD rats were separated into 3
groups (6 rats each group). The median nerve was partially transected (50%) – approximately three millimeters of nerve was removed in a longitudinal fashion. The three
groups were separated into immediate, two week, and four week study groups. The rats underwent grip strength testing as well as functional MRI testing. For the functional MRI testing the rat's median nerve was isolated for a second time and an electrode was placed distal to the excised area. The electrode was stimulated (10Hz
0.5mA, 5Hz 1.0mA). The cortical BOLD signal was compared to the left side intact median nerve BOLD signal as well as the database we have collected on intact right
median nerve BOLD signal. PRELIMINARY RESULTS: The BOLD signal in sensory cortex of the rat after stimulation of the partially transected median nerve appears less
than the intact left side and less than our previously obtained database. The grip strength in each of the groups appears to be approximately 50% of the intact side in all
groups. The figure is an example of the obtained BOLD signal of an intact direct nerve stimulation. DISCUSSION: We attempt to derive a model for partial transected
nerve donation in the rat. We hope to compliment grip strength tests with more objective determinants by looking at the cortical BOLD signal response in these nerves.
94
Is Denervation Superior to Epicondylectomy?
Institution where the work was prepared: Southern Illinois University , Springfield, IL, USA
Nada Berry, MD1; A. Lee Dellon, MD2; Michael W. Neumeister1; Robert C. Russell, MD, FACS3; (1)SIU School of Medicine, (2)Dellon Institute for
Peripheral Nerve Surgery, (3)Heartland Plastic Surgery
Introduction:
Lateral epicondylitis is the most common cause of lateral elbow pain in adults. Although non-surgical treatment is most effective, three to five percent of patients
require operative treatment for recalcitrant epicondylitis. Traditional treatment for this malady has been epicondylectomy, removal of damaged tendon, decortication of epicondyle, and possible repair of muscle insertion. Other approaches include posterior interosseous nerve (PIN) release, founded on release of the
superficial head of the supinator and leading to decreased tension onto the ailing epicondyle. Unfortunately, these procedures cite a sixty percent rate of symptom improvement, leaving the surgical outcome quite unpredictable. Recently epicondylar denervation has been used as another method of treatment. This study
will look at patients treated with neurectomy, and compare them to those treated with epicondylectomy.
Methods:
A retrospective chart review involving lateral epicondylitis patients was performed. All patients who underwent surgical treatment over the last 5 years were
included in the study. All patients had undergone attempted non-operative treatment, including a steroid injection. Group A consisted of patients with an epicondylectomy with or without PIN release, and Group B of patients with posterior cutaneous nerve of the forearm (PCNF) neuroctomy, with or without PIN
release.
Results:
Group A consisted of 13 patients, and Group B of 16 patients. Patients' age, sex, operated side, hand-dominance, level of residual pain, extent of numbness,
grip strength, and complication rates were compared.
Conclusion:
Epicondylectomy has been a traditional surgical treatment for tennis elbow. However, the result of treatment was unpredictable and has left many patients with
recalcitrant pain and continued symptoms. Denervation of the lateral epicondyle may be a more predictable and effective treatment for lateral epicondylitis.
95
ASPN Scientific Paper Session B
In Vivo Electrophysiologic Properties of poly(3,4-ethylenedioxythiophene)
PEDOT in Peripheral Motor Nerves
Brent M. Egeland, MD; Melanie G Urbanchek; Sarah M. Richardson-Burns; William M. Kuzon; Daryl R. Kipke, PhD; David C. Martin; Paul S Cederna;
University of Michigan
Objective:
Functional recovery following upper extremity amputation is an extremely difficult challenge, as a high fidelity, durable, peripheral nerve bioelectrical interface
remains elusive. We aim to develop a biologically integrated neural prosthetic interface that will sense peripheral nervous system (PNS) efferent motor action
potentials allowing electronic prosthetic control. The highly conductive, biocompatible compound poly 3,4-ethylene-dioxythiophene (PEDOT) polymerized on
acellularized muscle scaffolds (ACM-PEDOT) may fulfill these PNS interface requirements. We hypothesize that ACM-PEDOT biosynthetic peripheral nerve interfaces can sense and conduct in vivo efferent action potentials and that their electrophysiologic properties do not differ from intact motor nerve.
Methods:
In vivo peripheral motor nerve interface material conductivity and bioelectrical compatibility were tested using a rat peroneal nerve hind limb model. Interface
material test groups included: 1) acellularized muscle (ACM), 2) ACM treated with PEDOT polymerization reagent Iron (III) Chloride (ACM-Fe), and 3) ACMPEDOT. Positive controls included: 1) intact nerve (Intact), 2) epineural repair (Epineural), and 3) autogenous nerve grafts (Nerve Graft). Negative controls
included: 1) intact nerve treated with lidocaine to block action potentials (Intact-Lido), and 2) unreconstructed nerve gaps (Nerve Gap). Interfaces and nerve
gaps were further divided by length, measuring 0, 5, 10, 15 and 20mm. N=5 for each group. Epineural coaptations were performed proximally and distally. The proximal, native, peroneal nerve was immediately stimulated and electrophysiologic data including nerve conductive velocity (NCV), latency and extensor digitorum longus EMG response were recorded distal to the biosynthetic peripheral nerve interface. ANOVA with post-hoc analysis was performed for each
measured outcome with significance at p<0.05.
Results:
NCV/EMG results (Figure) demonstrate ACM-PEDOT conducts physiologic currents (0.53 ± 0.19 mA) up to 20mm with a maximal amplitude of 16.60 ± 5.29
mV, and latency of 1.09 ± 0.15 ms. This does not differ from intact nerve or similar length nerve autografts (power>0.8). ACM-PEDOT shows an increase in
NCV (40.22 ± 8.71 m/s) compared with intact nerve (22.15 ± 3.68 m/s). ACM and ACM-Fe interfaces were non-responsive above 10mm. There was no
conduction across unrepaired motor nerve gaps.
Conclusions:
PEDOT coated acellular muscle biosynthetic peripheral nerve interfaces can transmit physiologic efferent motor action potentials in vivo. We have initiated development of implantable, long term, integrated bioelectrical coupler using the PEDOT interface between the proximal nerve segment and electronics, with the ultimate goal of providing appropriate efferent control to a prosthetic limb.
Intraoperative nerve action potentials can determine optimal SSEP stimulus intensity
Institution where the work was prepared: Sunnybrook Health Sciences Centre, Toronto, Canada
David A. Houlden, PhD; Meghan Cohen; Samantha L. Robertson; Craig P. Stewart; Michael L. Schwartz; Mahmood Fazl; Farhad Pirouzmand; Sunnybrook
Health Sciences Centre
Introduction:
The optimal peripheral nerve stimulus intensity for somatosensory evoked potentials (SSEPs) is typically two times that necessary for muscle twitch threshold.
Unfortunately, muscle twitch may not be used during surgery because a) induction anaesthesia often requires neuromuscular blockade and b) some limbs may
not be viewed due to sterile drapes. Sub-optimal stimulation can lead to erroneous SSEP interpretation. We used intraoperative compound nerve action potential (CNAP) amplitude as a guide for optimal stimulus intensity, and compared it to muscle twitch threshold.
Methods:
After the patients were anaesthetized and neuromuscularly blocked, left then right ulnar nerves were alternately stimulated with surface electrodes at the wrist.
Evoked responses were obtained from Erb's point, the neck and the contralateral scalp (using signal averaging). Similarly, left then right tibial nerves were alternately stimulated with surface electrodes at the ankle, and evoked responses were obtained from the popliteal fossa, neck and the scalp. Maximum ulnar and
tibial nerve stimulus intensities were determined by increasing the stimulus intensity until the amplitude of the CNAPs from Erb's point and popliteal fossa (respectively) were just maximal (further increases in stimulus intensity failed to increase CNAP amplitude). At the end of surgery (after neuromuscular blockade was
gone and before emergence from anaesthesia) hypothenar and plantar foot muscle twitch threshold was determined by an individual blind to the CNAP data.
The stimulating electrodes were the same as those used in the CNAP study. Paired t-test compared the stimulus intensity for maximal CNAPs to that for muscle twitch threshold x 2.
Results:
20 consecutive patients undergoing brain and spine surgery were tested. There was no significant difference between the stimulus intensity derived from CNAP
amplitude and that derived from muscle twitch threshold x 2 for both ulnar and tibial nerves.
Conclusion:
The stimulus intensity necessary for maximum ulnar and tibial nerve CNAP amplitude is similar to that necessary for muscle twitch threshold x 2. Accordingly,
CNAP amplitude may be used to determine optimal SSEP stimulus intensity when muscle twitch is not available. This technique should improve the success of
intraoperative SSEP monitoring.
96
Neuropathy a Late Finding in the Post-Burn Population; a Four Year Institutional Review
Institution where the work was prepared: Saint Louis University, Saint Louis, MO, USA
Johnny Franco, MD; John Scott Ferguson; Saint Louis University
Introduction:
Nerve compression syndrome is a significant post-burn morbidity that can often be difficult to recognize and manage. Nerve compression can be caused acutely by direct compression from edema or eschar and in a delayed fashion by the formation of scar tissue or heterotropic bone formation. The incidence of neuropathy in the burn patient ranges from 2-15% depending on whether the diagnosis was made clinically or with electrodiagnostic studies.
Methods:
A four-year review of our institution's database found twenty-two patients that underwent peripheral neuroplasty. This patient population included both thermal and electrical burn patients. Two patients were excluded from the study as they underwent rapid forearm amputation. We reviewed the mechanism of burn;
percent body surface area burned, which nerves underwent decompression and time from burn to decompression.
Results:
Nerve compression syndromes were diagnosed and treated in this group of patients from day 279 to day 909 post-burn. Median nerve compression was the
most commonly diagnosed compression, accounting for 70% of the nerve decompressions. Seven-teen of the twenty (85%) patients required that multiple nerves
be decompressed.
Conclusions:
Nerve compression neuropathies secondary to burns can be a challenging problem to diagnose and treat. Multiple studies have shown the importance of treating
nerve compressions in the acute setting, however this study shows the importance of long-term surveillance, secondary to the late presentation of nerve compression
syndromes in patients with significant burns. The late nerve compression neuropathies were present in both the electrical and thermal burn patients. We also found
that presentation of one nerve compression should raise the suspicion of a synchronous nerve compression as 85% our patients had multiple nerve compression neuropathies. Patients with significant burns should be routinely questioned and examined for peripheral neuropathies during long-term follow-up.
Exogenous Administration of Nerve Growth Factor (NGF) Establishes a Biphasic
Dose-response on Early Peripheral Nerve Regeneration
[authors]Stephen W.P. Kemp, BSc(Hons), MSc; Douglas W. Zochodne; Rajiv Midha; University of Calgary
Previous research has examined the application of exogenous neurotrophic factors (NTFs) such as Nerve Growth Factor (NGF) to the microenvironment of the injured
nerve, attempting to produce a situation similar to that of target organ reinnervation. However, placement of NGF within the lumen of nerve guidance tubes has resulted in variable regenerative success, perhaps owing to poor bioavailability or the inability to directly delivery NGF to the regenerating microenvironment. We hypothesized that daily administrations of NGF delivered directly to the regenerating microenvironment would influence in vivo axonal regeneration. We sought: (1) to determine the most effective dose of NGF on early nerve regeneration in the rat using a T-tube conduit paradigm, and: (2) to determine potential mechanisms involved in
NGF mediated axonal regeneration. Animals were randomly assigned to one of five drug treatment groups (saline, 200, 800, 1600, or 2400 pg NG/day). Daily
injections of NGF were administered through the use of a microinjection port (MIP) connected to a silicone based T-tube chamber for 1 week. Analysis of early (1
week) axonal outgrowth was performed by rigorous and systematic counting of neurofilament (NF 200) positive profiles within longitudinal sections of the proximal
stump through the regenerating nerve bridge. Results of the study indicate that daily administration of NGF through a T-tube paradigm promoted a biphasic doseresponse effect, with a threshold effect seen at the 800 pg dose. Animals administered this dose displayed a significantly greater neurofilament profile within the nerve
cable than any other group. Animals administered high dose NGF (2400 pg) showed inhibited regeneration. These results imply that administration of NGF at a dose
of 800 pg is optimal in this model for enhancing early peripheral nerve regeneration. Ongoing studies are trying to determine the mechanism responsible for this
effect. We are currently investigating this question from two different perspectives. The first involves functionally blocking both the trkA receptor (using K252A) and
p75 NGFreceptor (using REX) with concurrent administration of high dose NGF to ascertain the basis of the inhibitory effect. The second approach involves analysis
of up or down-regulation of regenerative associated genes (RAGs) and transcription factors such as AKT, c-jun, and GAP-43 in the cell bodies of regenerating axons
in response to administration of different doses of NGF. These ongoing evaluations aim to determine optimal growth mechanics and conditions for regenerating peripheral axons in response to injury and neurotrophin administration.
Photochemical Sealing of Peripheral Neurorrhaphy, Improving Electrophysiological
and Histological Outcomes
Institution where the work was prepared: Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
Francis Patrick Henry, MD; Namita A. Goyal, MD; William S. David, MD, PhD; David Wes, BA; Mark A. Randolph, MAS; Irene E. Kochevar, PhD; Robert
W. Redmond, PhD; Jonathan M. Winograd, MD; Massachusetts General Hospital, Harvard Medical School
Introduction:
The microsurgical approach currently employed in the repair of peripheral nerve injuries rarely achieves full functional recovery and the intraneural scarring
which occurs adversely affects clinical outcome following repair. This study determines whether isolation of the nerve repair site using photochemical tissue
bonding (PTB) in combination with human amniotic membrane can improve both functional and histological recovery.
Methods:
Twenty four New Zealand White Rabbits underwent transection of the right common peroneal nerve. Epineural nerve repair was performed using 10/0 nylon
sutures. The repair site was then wrapped in a cuff of human amniotic membrane, which was either secured with sutures (n=8) or sealed using PTB (n=8).
Standard neurorrhaphy alone was assessed as a control group (n=8). Functional recovery was recorded at 30 day intervals post-operatively by electrophysiological assessment. At 120 days animals were sacrificed and nerves harvested for histomorphometry.
Results:
Nerves treated with amnion wraps, sealed with PTB demonstrated a statistically significant improvement across both functional and histological parameters.
Functional recovery, as measured by repeated electrophysiological studies over time, revealed a 26.2% improvement over standard neurorrhaphy alone
(p<0.05). Nerves treated with PTB sealed amnion wraps had significantly (p <0.001) greater axon (5.08 ± 1.06µm) and fiber diameters (7.46 ± 1.37µm) as
well as myelin thickness (2.39 ± 0.7µm) and G-ratio (0.68 ± 0.07) distal to the repair site compared to standard neurorrhaphy alone (4.98 ± 1.81µm, 6.77
± 1.94µm, 1.79 ± 0.42µm and 0.71 ± 0.09 respectively).
Conclusion:
Isolation of the repair site using a photochemically sealed amnion wrap significantly improves electrophysiological and histological recovery when compared
to that of standard suture neurorrhaphy.
97
Lipofibromatous Hamartoma: A spectrum of nerve involvement
Jenny C. Lin, MD, PhD1; Suan Cheng Tan, MD2; Eric Arruda2; Matthew J. Lax, MD2; Dimitri J. Anastakis, MD, MHPE, MHCM2; (1)Hôpital Ste-Justine,
(2)University of Toronto
Purpose:
Lipofibromatosis hamartoma (LFH) is a rare benign condition of peripheral nerves characterized by the proliferation of adipocytes between fascicles. LFH has
been characterized by the involvement of single distal peripheral nerves often in association with nerve compression. There are only three documented cases
of LFH involving the brachial plexus. Using MRI, this study aims to investigate the incidence of brachial plexus involvement in patients diagnosed with characteristic distal focal LFH of the upper limb.
Method:
Seven patients with LFH of the upper limb (total of eight affected limbs) were studied. MRI images were obtained from the metacarpo-phalangeal joints to the
nerve roots. Each extremity was imaged in 2-3 sections with axial and longitudinal acquisitions. The brachial plexus was imaged in the coronal, sagittal and
axial planes. T1-W and T2-W fat-saturated sequences were acquired.
Results:
Four limbs (50%) showed LFH involvement of the cords of the brachial plexus, demonstrated by thickening and increased intervening fat signal. Of these, three
demonstrated involvement of multiple nerves. The fourth had continuous LFH of the entire ulnar nerve. The other limbs studied showed no involvement of the
brachial plexus. Two had isolated distal median nerve involvement, and two had discontinuous median nerve involvement.
Conclusion:
In our study, contrary to the usual description of LFH in the literature, 50% of limbs with seemingly focal disease had brachial plexus involvement. Based on the
LFH patient's specific clinical findings, additional MRI of the brachial plexus may be indicated. LFH may represent a spectrum of disease; from focal nerve
involvement to a more wide-spread condition also affecting the brachial plexus.
Brachialis Nerve Transfers for Lower Brachial Plexus Reanimation
Institution where the work was prepared: Renata Weber, Bronx, NY, USA
Renata V. Weber, MD; Montefior Medical Center/Albert Einstein College of Medicine; Thomas HH Tung; Washington University in St. Louis; Susan E.
Mackinnon, MD; Washington University College of Medicine
Introduction:
Nerve transfers for shoulder and elbow reanimation have been extensively described; however, transfers for lower brachial plexus injuries have not been as
successfully established. Because of the greater distance to the target muscles, transfers to the median and ulnar nerves in the proximal forearm were presumed
to result in poor outcomes. We present up to 3 year follow up of 2 patients who underwent successful lower plexus reanimation by using the brachialis nerve
branch of the musculocutaneous nerve.
Methods:
2 cases of adult brachial plexus lower trunk injury were treated by neurotizing one of the nerve branches to the brachialis muscle to the anterior interosseus
nerve using a nerve graft in the proximal forearm (patient 1) and to the ulnar nerve in the distal upper arm (patient 2). Recovery of function, grip strength,
nerve electrophysiology and muscle power of the affected limbs were observed and measured.
Results:
Patients first began to showed clinical recovery at around 13-14 months, with final pinch and grip strength plateauing around 2 years from surgery. At least
M3 strength was observed in hand flexion and no decrease in elbow flexion strength from the pre-operative state was noted.
Conclusions:
Despite the proximal location of these transfers, the brachialis branch of the musculocutaneous nerve can be used to reanimate the hand and fingers in selected patients with good functional outcome
Transplantation of Olfactory Ensheathing Cells Enhances Peripheral Nerve Regeneration after Microsugical Nerve Repair
Institution where the work was prepared: Department of Plastic, Hand- and Reconsructive Surgery, Hannover, Germany
Christine Radtke1; Ayal A. Aizer, MD2; Karen L. Lankford2; Peter M. Vogt1; Jeffery D. Kocsis2; (1)Hannover Medical School, (2)Yale University School of
Medicine
While axonal regeneration is far more successful in peripheral nerve than in the central nervous system, it is by no means complete and research to enhance
peripheral nerve regeneration is clinically important. Olfactory ensheathing cells (OECs) are known to enhance axonal regeneration and to produce myelin
after transplantation. In contrast to Schwann cells their migratory potential and ability to penetrate glial scars is higher. This study evaluated the effect of OEC
transplantation on microsurgically repaired sciatic nerves.
Rodent sciatic nerves were transected followed by microsurgical repair and transplantation of labelled OECs. Twenty-one days later the nerves were removed
and prepared for either histology or electrophysiology. All animals were functionally tested using footprint analysis.
The OECs survived and integrated into the repaired nerves as indicated by eGFP-expressing cells aligned with neurofilament identified axons bridging the
repair site. Moreover, regenerated Axons were myelinated by the transplanted OECs and nodes of Ranvier were formed. Conduction velocity in the OEC transplant group was increased in comparison to the microsurgical repair alone, and improved stepping was observed in the transplant group.
OECs transplanted at the surgical repair site of a transected nerve bridged the lesion site and associated with regenerated axons. Conduction velocity and number of regenerated axons were increased in the transplant group, and stepping behavior was improved. These results suggest that presentation of OECs at the
time of nerve injury enhances regeneration and improves functional outcome. Even a modest improvement in nerve regeneration could have significant clinical implications for reconstructive nerve surgery.
98
Anatomical Variations of Occipital Nerves: Clinical Applications for Surgical
Treatment of Occipital Neuralgia
Ivica Ducic, MD, PhD; Ali Al-Attar, MD; Georgetown University Hospital
Introduction:
According to the National Headache Foundation, an estimated 28-million Americans suffer from chronic headaches. This has significant impact on quality of
life of these patients as well as days lost from work. It is also postulated, among other factors that a compression of occipital nerves can trigger headaches.
Number of reports suggests successful application of surgical techniques for treatment of occipital neuralgia related headaches, and anatomical variations that
can impact diagnostic and therapeutic treatment of these patients, as we also observed.
Methods:
Thirtheen cadavers and 112 patients intraoperatively underwent measurements of greater and lesser occipital nerve. These findings were compared to what
current understandings of anatomy are, as presented in common books or atlases.
Results:
Greater occipital nerve (GON, n=125) was found to have an average diameter of 3.1 ± 1.6 mm, emerged through semispinalis capitis muscle 14.4 ± 4.5
mm from midline, and 30.2 ± 5.1 mm below occipital protuberance. It pierced trapezius muscle fascia 37.8 ± 4.6 mm from protuberance. In only 1.5% of
measurements, the nerve went medial to the muscle. Six percent of GON was split with muscle fibers, while in 44% there was asymmetry observed in measurements between left and right side. Lesser Occipital Nerve (LON, n=35) at the horizontal line 3 cm below occipital protuberance was in 85% found along
the posterior border of sternocleidomastoid muscle, while in 15% its location varied (from within 1 cm of GON to mid superficial surface of sternocleidomastoid muscle). Its average diameter was 1.2 ± 1.6 mm.
Conclusions:
Based on these findings, actual direction of nerve paths is different than what current anatomical atlases show, as will be presented. These observations can
further improve diagnostic (nerve blocks) and therapeutic (peripheral nerve surgery) treatment options of these patients, as well as better explain patho-physiological processes responsible for their presentation.
A Quantitative Evaluation of Gross Versus Histologic Neuroma Formation
in a Rabbit Forelimb Amputation Model
Jason H. Ko, MD1; Peter S. Kim, MD1; Kristina D. O'Shaughnessy, MD1; Todd A. Kuiken, MD, PhD2; Gregory A. Dumanian, MD1; (1)Northwestern
University Feinberg School of Medicine, (2)Rehabilitation Institute of Chicago
Background:
Targeted reinnervation is a novel procedure whereby nerve function in a previously amputated nerve is reestablished by performing a nerve transfer to a nearby
functioning smaller nerve. Until now, the majority of neuroma surgery involved the making of symptomatic neuromas less bothersome; however, with targeted reinnervation, there is now a need to understand the “zone of injury” that occurs to a nerve after transection. Given the anterograde degenerative changes that occur
after nerve injury, the question remains whether cutting the amputated nerves more proximally where they are more histologically “normal” will help promote a
more effective nerve transfer procedure. We investigated the gross and histologic changes to transected nerves in a quantitative manner using a rabbit forelimb
amputation model previously developed in our laboratory.
Methods:
Four New Zealand white rabbits underwent a left forelimb disarticulation amputation with transection and preservation of the median, radial, and ulnar nerves 2cm
distal to the brachial plexus. After 6-8 weeks, the distal 5mm of neuroma was excised, and serial sections of the amputated nerves were then obtained at the remaining distal end and at 5mm, 10mm, and 15mm proximally toward the brachial plexus. Serial sections at corresponding lengths were also obtained from the contralateral forelimb as controls, and all nerve specimens underwent histomorphometric analysis.
Results:
All nerves demonstrated statistically significant increases in nerve cross-sectional area between treatment and control limbs at the distal nerve end, but these differences were not observed more proximally (Figure). At the axonal level, an increased number of myelinated axons were seen at the distal end of all amputated
nerves, but this increase was not present in any nerves 10mm proximal to the amputation. However, unlike nerve area and axon number, the cross-sectional area
of myelinated axons was significantly decreased in all serial sections except for the most proximal portion of the ulnar nerve, indicating that degenerative axonal
changes proceed proximally to the level of the brachial plexus and potentially beyond.
Conclusion:
Gross neuroma formation, represented by nerve cross-sectional area, does not correlate with the degenerative changes that occur proximally at the axonal
level after an amputation injury. Excision of the amputation neuroma as far proximally as possible may help promote a stronger neurotization signal in future
targeted reinnervation procedures.
99
Characterization of a Novel Transgenic Rat Line Over-expressing Green Fluorescent Protein (GFP)
Rahul Kasukurthi, BA1; Amy Moore2; Alice Y. Tong1; Nancy Solowski, MD, MS2; Janina Luciano2; Ying Yan1; Wilson Z. Ray1; Susan E. Mackinnon2;
Gregory Borschel2; (1)Washington University School of Medicine, (2)Washington University
Purpose:
Transgenic mice that express fluorescent proteins in their neurons have been integral to the study of nerve growth and regeneration. One limitation of these animals
is their nerve caliber; small diameter nerves cannot be practically accessed and utilized in a certain mouse models, such as in the head and neck. A larger transgenic rat model with excellent regenerative capabilities would be a tremendous asset to the field of neuroscience. The purpose of this study was to characterize the
expression of green fluorescent protein (GFP) in a newly developed transgenic rat model.
Methods:
Two transgenic Sprague Dawley lines were created using pronuclear injection of a transgene expressing GFP under the control of a Thy1 promoter. PCR and
Southern blot screening were performed on genomic DNA to confirm the integrity of the transgene. F2 generation rats that contained the desired transgene
underwent characterization studies to determine the expression of GFP. Nerve and muscle tissue from naïve rats were evaluated for expression of GFP using
in vivo fluorescent and confocal microscopy. Serial live in vivo imaging was performed to evaluate nerve regeneration after a sciatic crush injury.
Results:
Preliminary results indicate that both transgenic rat lines demonstrate GFP expression in their neurons and this expression extends to the neuromuscular junction with one to one motor endplate innervation. Serial imaging after a crush injury indicates these animals can be used to directly monitor nerve regeneration.
Conclusions:
The generation of a novel transgenic rat model expressing green fluorescent protein (GFP) will prove to be a valuable addition to the field of peripheral nerve
research. While in vivo study of transgenic mice is limited by their small size, GFP expressing rats will allow in vivo evaluation of nerves in a wider array of
surgical models, such as increased gap lengths. This novel transgenic line will not only allow the use of traditional functional outcome measures validated in
non-fluorescent rat models, but also new outcome measures ranging from serial imaging to direct motor endplate analysis.
The Role of BFGF and NGF in the Treatment of a Common-Peroneal-Nerve
Gap by Means of Autologous Nerve Grafting In Rats
Institution where the work was prepared: General Hospital "Asclepeion Voulas", Athens, Greece
Eleni Ntouvali, MD1; Spyridon Deftereos, MD2; Theodoros Filippidis, MD3; Michalis Sideris4; Grigorios Panagopoulos, MD2; Apostolos Papalois, PhD4;
Panagiotis Athanasiou Kinnas, MD1; (1)General Hospital "Asclepeion Voulas", (2)General Hospital "G. Gennimatas", (3)MICROMEDICA, (4)ELPEN
Pharmaceuticals
Purpose:
This study aimed at investigating the results of autologous nerve grafting of a 10mm common-peroneal-nerve (CPN) gap in rats,after intraoperative subepineurial administration of bFGF and/or NGF.Material:Five(5) groups of adult male Wistar rats were studied,according to the following protocol:I.Autologous nerve
grafting[4 groups: D(bFGF 20ng),E(NGF 25ng),F(normal saline),Y(bFGF 20ng + NGF 25ng)] and II.Negative control group(G).
Methods:
In groups D,E and Y,a 10mm-long segment was sharply cut off from the CPN,at a distance of 7mm distal to its origin from the rat sciatic nerve,then sutured
back in place,in order to serve as a nerve autograft.Subsequently,50Ìl of the corresponding solution of growth factor(s) was administered subepineurially to the
CPN proximal to the proximal autograft suture site.The same surgical procedure was carried out in group F,but an equal volume of normal saline was administered instead.Finally,in group G,after sharp division of the CPN 7mm distal to its origin,both its proximal and distal stumps were sutured into the neighbouring muscles.All surgical procedures took place with the animals under dissociative anaesthesia and were performed under sterile conditions,using the operating microscope and applying microsurgical techniques.In each case,the intact left CPN served as intraanimal control.
Results:
The evaluation of the outcome four(4) months postoperatively was based on clinical examination,walking-track analysis,in situ electromyographic studies,Tib.
cranialis "wet muscle mass" measurement and histomorphometric studies.Statistical analysis of the data regarding nerve histomorphometry revealed the following:bFGF alone was better than placebo.NGF alone was superior not only to placebo,but also to bFGF alonen the other hand,the combination of
(bFGF+NGF) was inferior to either growth factor alone as well as to placebo.All of the aforementioned differences were statistically significant (p<0.05).
Conclusions:
In rats,intraoperative administration of bFGF and/or NGF once subepineurially enhanced the results of CPN autologous nerve grafting 4 months postoperatively,with an apparent advantage of NGF.
100
ASPN Scientific Paper Session C
Existence of Neurites Promote Differentiation of Dermal Fibroblasts into Myofibroblasts and Induce Contraction of Collagen
Matrix in Vitro
Institution where the work was prepared: Osaka University Graduate School of Medicine, Osaka, Japan
Tateki Kubo, MD, PhD; Toshihiro Fujiwara; Kenji Yano; Ko Hosokawa; Osaka University Graduate School of Medicine
Introduction:
Neurites of sensory neurons in the skin may be necessary for the normal wound healing, since wound healing is often delayed in the patients whose sensory
innervation is impaired such as spina bifida and spinal cord injury. Therefore, we hypothesize that existence of the neurites in the skin may promote wound
healing by inducing differentiation of dermal fibroblasts into myofibroblasts, which is essential for normal wound healing. In the current study, we examine
the effect of neurites on the differentiation of fibroblasts and on the contraction of collagen matrix in vitro, which mimics wound contraction.
Methods:
Neuronal cell line, PC 12 cells, whose neurite outgrowth can be controlled by adding nerve growth factor (NGF), are used in this study. PC 12 cells start
extending their neurites by adding the NGF in the culture medium. Rat dermal fibroblasts are co-cultured with PC 12 cells extending neurites (PC12-NGF (+))
or with PC 12 cells lacking neurites (PC12-NGF(-)). Then, differentiation of fibroblasts into myofibroblasts is confirmed with myofibroblasts maker, a-smooth
muscle actin (SMA) using immunocytochemistry. PC 12-NGF (+) or PC12-NGF (-) are plated on the collagen matrix including rat dermal fibroblasts, and a
contraction of matrix, which mimics wound contraction, is evaluated. Expression of a-SMA mRNA in the collagen matrix is also examined by real time RT-PCR.
Finally, we examine which is more important for the differentiation of fibroblasts, direct or indirect (chemical) contact of neurites with fibroblasts.
Results:
Fibroblasts co-cultured with PC 12-NGF (+) were induced to myofibroblasts more effectively than those with PC 12-NGF (-). Collagen matrix including fibroblasts and PC-12 NGF (+) contracted larger, and expressed more a-SMA mRNA, in comparison to PC12-NGF (-) collagen matrix. Direct contact of neurites
with fibroblasts promoted differentiation into myofibroblasts.
Conclusion:
Neurite outgrowth was important for the differentiation of dermal fibroblasts into myofibroblasts. PC 12 cells extending neurites induced contraction of collagen matrix and a-SMA mRNA expression by fibroblasts. Direct contact of neurites with fibroblasts was more effective for their differentiation into myofibroblasts rather than indirect (chemical) contact.
Contralateral C7 Transfer for Complete Brachial Plexus Avulsion
Institution where the work was prepared: Johns Hopkins, Baltimore, MD, USA
Michael J. Dorsi, MD; Allan J. Belzberg, MD, FRCSC; Johns Hopkins School of Medicine
Introduction:
In cases of pan-plexus root avulsion, the extent of injury overwhelms the capacity of intact regional nerves available for nerve transfer. Over the past 7 years, we have attempted to restore function by transferring the contralateral C7 root to the injured brachial plexus in five patients with complete avulsion.
Methods:
The median age at was 18.1 years (range 5-35yr) with a median interval between injury and surgery of 4.5 months. Targets included: upper trunk (n=4), axillary nerve (n=2), and musculocutaneous nerve (n=1). The median follow-up was 3.7 years.
Results:
Transfer of C7 to the upper trunk in 4 patients resulted in recovery of supraspinatus > M3 in 2/4 patients; biceps > M4 in 4/4 patients; deltoid to > M4 in one
patient; triceps to > M4 in one patient. Distal coaptation to the musculocutaneous nerve produced recovery of M2 strength in one patient. Distal transfer to the axillary nerve in 2 patients resulted in deltoids recovery of M2 strength in one, and M0 in the other. Sensory recovery > S2 following coaptation to the upper trunk was
achieved in the lateral antebrachial cutaneous(LABC) in 4 patients and the median and radial nerve in 3 of 4 patients. Distal transfer to the musculocutaneous nerve
did not restore LABC sensation. Two of five patients experienced transient paraesthesias in donor side hand. One patient experienced neuropathic pain in the contralateral hand that developed 5 weeks after surgery and subsided completely within one year. The youngest patient in our series was able to contract the muscles
reinnervated by C7 without volitional contraction of the muscles of the donor limb. The remaining four patients had to volitionally contract the muscles of the donor
limb to evoke movement of the injured limb. For one patient, extension of the donor limb evoked inadvertant injured limb contraction which limited the usefullness
of the injured limb. Despite objective improvement in strength and sensation only 3 of 5 patients reported recovery of useful function.
Conclusion:
Our findings are in accordance with prior series that have shown favorable motor and sensory recovery with only transient neurological disturbances in the
donor-side limb following C7 transfer. However, restoration of useful function was limited by the lack of neural plasticity. Younger patients, with a greater potential for central adaptation, are the best candidates for contralateral C7 transfer.
101
Functional Bio-Artificial Neuro-Muscular Implant for Peripheral Nerve Interfaces
Mohammad Reza Abidian, MD; Eugene Dariush Daneshvar; Melissa Wright; Brent Egeland, MD; Melanie Urbanchek; Rachel Miriani; Paul S. Cederna, MD; Daryl R.
Kipke, PhD; University of Michigan
A functional chronic interface with the peripheral nervous system, which would allow for recording as well as stimulation, would open the door to a number of new devices
for treatment of some peripheral nervous system (PNS) defects such as nerve gap and amputation. We are currently working to develop a novel bioartificial neuromuscular interface (BANMI), which will eventually be used as a functional chronic device for connection between PNS and an artificial arm. This device consists of 1) a soft
and permeable hydrogel micro-tube (800 ?m in diameter, 200±50 ?m wall thickness and 10±2 mm long), which guides nerve growth and provides nutrition factors from
surrounding tissue for the nerve, 2) electro-polymerized conducting polymer poly(3,4-ethylenedioxythiophene) (PEDOT) on microfabricated electrode sites (1250 ?m2),
which allow recording and stimulation of the nerve to monitor and promote regeneration, and 3) a bioactive scaffold for proliferation of myocytes, which facilitates formation between a neuromuscular junction and a neural electrode and may also amplify the recording signals. Previously we showed that PEDOT could improve the electrical properties of microfabricated neural electrodes for recording and stimulation. We first evaluated the biocompatibility of PEDOT in-vitro using cultured dorsal root
ganglion cells and myocytes. Then we successfully fabricated agarose micro-tubes and coated porous PEDOT nanostructures inside the lumen. This novel conduit was
implanted in a 1 cm nerve gap in a rat and was compared with poly dimethylsiloxane tubes in terms of nerve regeneration. Finally, we fabricated an array of microelectrodes and inserted them into the BAMNI in order to record and stimulate the nerve for monitoring and augmenting regeneration. We are going to implant functional
BAMNI tubes to evaluate the effects of stimulation. We will examine the nerve-material interface with florescence and confocal microscopy. The regeneration of nerve
inside the BAMNI will be evaluated functionally using walking track assessments during the recovery phase. At the 10-week endpoint we will also evaluate the nerve conduction (the proximal peroneal nerve will be stimulated and electrophysiologic data including nerve conductive velocity, latency and extensor digitorum longus EMG
response will be recorded), muscle mass, muscle contraction force, and nerve histology including number of axons, diameter of axons, thickness of myelin sheath.
Role Of Microsphere Delivered Nerve Growth Factor (NGF) And Glial Cell Line
Derived Neurotrophic Factor (GDNF) In Peripheral Nerve Regeneration
Ralph De Boer, MD1; Andrew M. Knight, PhD1; M.J.a. Malessy2; Robert J. Spinner1; A.J. Windebank, MD1; (1)Mayo Clinic, (2)Leiden University Medical Center
Introduction:
The current gold standard for repair of a nerve gap is the interposition of an autologous nerve graft. This has several disadvantages, such as donor site morbidity, limited availability, size mismatch and painful neuroma formation. In addition, functional recovery rarely returns to pre-injury level. Therefore, the development and optimization of nerve conduits is an increasingly important focus in the field of peripheral nerve regeneration. One promising approach that may enhance nerve regeneration is
prolonged delivery of growth factors. In our lab, we have previously studied the long term release of NGF using a microsphere delivery system. In this study, we evaluate
the effect of growth factor releasing microspheres on functional regeneration using polymer nerve conduits.
Methods:
Poly-lactic-co-glycolic-acid (PLGA) nerve conduits were used to bridge a 10 mm gap in a rat sciatic nerve injury model. Conduits were loaded with either GDNF, NGF, GDNF-microspheres or NGF-microspheres at 3 different concentrations. An autograft and a conduit filled with saline were used for comparison. Electrophysiological (CMAP) and motor testing (2D
video motion analysis) were carried out at regular intervals after surgery. Retrograde tracing of fast blue to ventral horn and dorsal root ganglion neurons, as well as morphometry of
sciatic nerves is being performed at 16 weeks.
Results:
Conduits filled with NGF-microspheres showed a trend towards higher CMAP amplitude at endpoint in comparison to autografts. Motion analysis and nerve morphometric data are being processed.
Conclusion:
PLGA conduits provide excellent scaffolds for peripheral nerve repair and can be used to optimize delivery conditions for growth factors such as NGF and GDNF.
Improved Regeneration of Autologous Nerve Transplants by Means of VEGF-Gene Therapy
Institution where the work was prepared: Department of Plastic Surgery and Hand Surgery, Munich, Germany
Riccardo E. Giunta1; Thomas Holzbach1; Rupprecht Milojcic1; Thomas Brill2; Kaspar Matiasek1; Martina Anton2; Bernd Gänsbacher2; Hans-Günther Machens1;
(1)Klinikum rechts der Isar, Technische Universität München, (2)Technische Universität München
The impact of the Vascular Endothelial Growth Factor (VEGF) on the angiogenic cascade is proven. Recently its neuroprotective effect after peripheral nerve injuries on ?motoneurons in the spinal cord was shown. The biological effect is mainly mediated by the binding of two tyrosine kinase receptors (VEGFR1&VEGFR2), but in addition
an effect via Neuropilin (NP)-1 and NP-2, receptors essential for the development of the nervous system, was reported. Thus a sprouting of axons could be monitored as
well as an improved survival of neurons and glial cells. Experiments on ?-motoneurons demonstrated a decreased sensitivity to ischemia under VEGF-therapy.
In the model of a peripheral nerve defect treated with an autologous nerve transplant in the rat we want to elucidate the effect of a localized VEGF-gene-therapy using
an adenoviral vector construct.
A 2cm segment was resected in the course of the right sciatic nerve of the rat (n=24) and reversely coapted under the microscope in terms of an autologous interposition.
Thereafter we injected a total volume of 200?l Ad.CMV.VEGF165 (108pfU) in 4 fractions into the surrounding muscle and sheet. During the trial period of 18 weeks we
conducted weekly walking-track and static foot-print-analyses. After 18 weeks the gastrocnemius muscle was weighed and evaluated electrophysiologically, the axons in
the sciatic nerve were counted as well as the ?-motoneurons of the corresponding neuronpool in the spinal cord. Additionally we evaluated the coaptation sites histologically.
In the experimental groups we detected signs of reinnervation earlier than in controls, the innervationindex at the end was significantly increased in VEGF-experimental
groups (66% of opposite side) when compared to controls (48%; p<0.05). The muscle weight was significantly increased, as well (57% vs. 48% of opposite side; p<0.05).
The electrophysiological assessment yielded significantly higher amplitude between tarsus and trochanter (p<0.05) with comparable conduction time.
Local VEGF-Gene-Therapy produced a quicker nerval regeneration with an improved functional outcome in this setting. These results cannot only be explained by a quicker incorporation of the transplant by dint of induced angiogenesis but rather by a direct impact on neurons resp. axons. Notwithstanding the impact of these findings a
transfer into clinic appears limited due to the used vector construct.
102
Aligned Conducting Polymer Nanotubes for Contact Guidance of Neurite Outgrowth
and Precisely Controlled Release of Neurotrophins in Nerve Regeneration Applications
Mohammad Reza Abidian, MD; Joseph M. Corey, MD, PhD; David C. Martin, PhD; Daryl R. Kipke; University of Michigan
In the peripheral nervous system, nerves can regenerate on their own if injuries are small (~ < 1 cm). Unfortunately, a solution to completely repair spinal cord
injury or larger injuries in peripheral nervous system has not been found. Textured implants for neural guidance hold promise approach for controlled neural
regeneration. We have developed methods to create aligned conducting polymer nanotubes (ACPN) that can precisely control the local release of neurotrophins,
and can provide guidance for directed neurite outgrowth. The fabrication process involves the electrospinning of aligned biodegradable poly(lactid-co-glycolid)
nanofibers into which nerve growth factor (NGF) have been incorporated followed by electrochemical deposition of conducting polymer poly(3,4-ethylenedioxythiophene) (PEDOT) around the nanofibers. The electrical properties and surface morphologies of nanotube coatings were examined in vitro. Dorsal root
ganglion (DRG) explants, and PC12 cells were cultured on these ACPN. Scanning electron, fluorescence and confocal microscopy results revealed that cells could
be patterned and preferentially guided in the direction of the PEDOT nanotube orientation. The Enzyme-Linked ImmunoSorbent Assay (ELISA) and PC12 cell
culture experiments confirmed retained bioactivity of NGF during the fabrication process. Electrical actuation (as small as 0.5V) of PEDOT nanotubes leads to
precise release of NGF (10 ng/ml) at desired points in time, and this is directly correlated with controlled neurite outgrowth. NGF loaded aligned PEDOT nanotubes will be placed in the polymeric micro-tubes and implanted in a rat in order to promote the regeneration of axons in a 2 cm nerve gap. The regeneration of nerve will be evaluated functionally using walking track assessments during the recovery phase. At the 15-week endpoint we will also evaluate the nerve
conduction (the proximal peroneal nerve will be stimulated and electrophysiologic data including nerve conductive velocity, latency and extensor digitorum longus
EMG response will be recorded), muscle mass, muscle contraction force, and nerve histology including number of axons, diameter of axons, thickness of myelin
sheath.
Comparative Gene Expression Profiling Provides Novel Insights in the Molecular Basis
of Misrouting of Axons Through the Neuroma in Continuity in Obstetrical Brachial Plexus Injuries
Institution where the work was prepared: Netherlands Institute for Neuroscience, Amsterdam, Netherlands
Martijn R. Tannemaat, MD1; Koen Bossers1; M.J.a. Malessy2; Joost Verhaagen1; (1)Netherlands Institute for Neuroscience, (2)Leiden University Medical
Center
Obstetrical Brachial Plexus Injuries (OBPI) are caused by traction which typically results in the formation of a neuroma in continuity. In the absence of a gap
between two nerve stumps, the connecting neuroma in continuity may serve as a bridge for regenerating axons. Some level of spontaneous recovery should,
therefore, be possible. We applied genome wide gene expression profiling as a first step to identify the molecular mechanisms that play a role in the process
of axonal regeneration and misrouting in neuroma tissue formed after OBPI.
Methods:
A group of 22 surgically treated OBPI infants were studied. Preoperative electromyography of the biceps muscle was performed and Motor Unit Potentials
MUPs were recorded at 1, 4 and 12 weeks. Intraoperative Nerve Action Potentials (NAPs) and Compound Motor Action Potentials (CMAPs) over the superior trunk neuroma in continuity were documented. Immunohistochemistry was performed for Neurofilament to stain axons in the neuroma in continuity and
proximal stumps. Micro-array analysis was carried out to compare gene expression in the neuroma tissue to the proximal C5 or C6 stump from the same
patient.
Results:
MUPs were documented in the biceps at three months in almost all infants, although elbow flexion was absent. NAPs and CMAPs were recordable in all babies.
Immunohistochemistry showed a reduced density and criss-cross growth pattern of axons. Furthermore, axons were oriented in patterns that are highly suggestive for the presence of axonal guidance cues in the neuroma in continuity. Micro-array based gene expression analysis identified 722 genes that are differentially regulated in the neuroma. The Gene Ontology classes “extracellular matrix”, “cell adhesion” and “axon guidance” are significantly overrepresented in the list of regulated genes. A total of 18 genes with a previously documented role in axonal guidance were differentially expressed. Immunohistochemical
staining for Versican, one of the differentially regulated genes, showed that this proteoglycan is selectively expressed in the vicinity of regenerating axons.
Conclusion:
In depth analysis of the superior trunk neuroma in continuity of OBPI infants shows anatomical axonal continuity with conducting properties through the lesion
site in the absence of functional recovery. The density of axons appeared reduced and axonal routing was severely disturbed. A unique combination of differentially expressed genes was identified that may govern the disturbed axonal regeneration process in neuroma tissue. These targets can form the starting point
for the development of novel therapeutic intervention strategies aimed at promoting functional recovery following OBPI.
103
RGTA, a Synthetic Glycosaminoglycan Mimetic, Significantly Reduces
Neural Adhesions after Peripheral Nerve Injury in Rats
Institution where the work was prepared: Erasmus MC, Rotterdam, Netherlands
H. Mischa Zuijdendorp1; Xander Smit, PhD1; B.Stefan de Kool1; Joleen H. Blok, PhD1; Jean Pierre Caruelle, PhD2; Barritault Denis, PhD2; Steven E.R.
Hovius, Prof, PhD1; J.W. van Neck, PhD1; (1)Erasmus MC, (2)Université Paris XII-Val de Marne
Aims:
Extra- and intraneural scar formation after peripheral nerve injury frequently causes tethering and compression of the nerve as well as inhibition of axonal
regeneration. ReGeneraTing Agents (RGTAs) mimic the stabilizing and protective properties of sulphated glycosaminoglycan (GAG) towards heparin-binding
growth factors (HBGFs). The aim of this study was to assess the effect of a RGTA, named OTR4120, on extraneural fibrosis and axonal regeneration after crush
injury in a rat sciatic nerve model.
Methods:
Thirty-two female Wistar rats underwent a standardized crush injury of the sciatic nerve. The animals were randomly allocated to RGTA treatment or sham
treatment in a blinded design. To score neural adhesions, the force required to break the adhesions between the nerve and its surrounding tissue was measured 6 weeks after nerve crush injury. To assess axonal regeneration, magnetoneurographic (MNG) measurements were carried out after 5 weeks. Static footprint analysis was performed preoperatively and 1, 7, 14, 17, 21, 24, 28, 35, and 42 days postoperatively.
Results:
MNG data show no significant difference in conduction capacity between the RGTA and the control group. In addition, results of the static footprint analysis
demonstrate no improved or accelerated recovery pattern. However, the mean pull-out force of the RGTA group (67 g; SEM 9 g) was significantly (p<0.01)
lower than that of the control group (207 g; SEM 14 g).
Conclusion:
RGTAs strongly reduce nerve adherence to surrounding tissue after nerve crush injury. The experimental protocol was approved by the Animal Experiments
Committee under the national Experiments on Animals Act, and adhered to the rules laid down in this national law that serves the implementation of the
“Guidelines on the protection of experimental animals” by the Council of Europe (1986), Directive 86/609/EC.
The Medial Intermuscular Septum and the ulnar nerve
Institution where the work was prepared: Kleinert Institute for Hand and Microsurgery, Louisville, KY, USA
Tuna Ozyurekoglu, MD; Christine M. Kleinert Institute for Hand and Microsurgery
Background:
The purpose of this study is to investigate the relation of the ulnar nerve to the medial intermuscular septum and possible musculotendinous arcades, and to
determine if these arcades represent a primary site of compression.
Methods:
31 lightly embalmed fresh cadaver upper limbs (16 left, 15 right) in 19 human specimens were dissected. The medial side of the arm was exposed using a
dissection technique that did not damage or displace the ulnar nerve or the tendinous fibers of the septum. Presence and characteristics of the septum and
arcades were documented. The ulnar nerve was examined for signs of compression: increased local vascularity, hourglass deformity, local scarring.
Results:
The ulnar nerve crossed from the anterior to the posterior compartment of the arm, with a significant variation, at 8 to 19 cm proximal to the medial epicondyle
(mean: 13.2 cm). The ulnar nerve entered the posterior compartment 1) very proximally and superficially in 11 of the 31 arms without any tendinous structures over it(The Ulnar Nerve Superficial Group (35%)); 2) distally and deeply in 13 of the 31 arms piercing the medial intermuscular septumand forming an
arcade within (The Medial Intermuscular Septum Arcade Group (42%)); and 3) proximally, but deeply in 7 of the 31 arms under an arcade within the medial
head of Triceps(The Triceps Arcade Group (23%)). 11 of the 20 arms with an arcade showed distinct signs of compression in the Triceps and the medial intermuscular septum arcade groups in contrast to none in the 11 ulnar nerve superficial arms.
Conclusions:
The relation of the ulnar nerve and the medial intermuscular septum seemed to be totally randomly determined by how proximal and how deep it crossed the
arm from anterior to posterior. During this passage arcades are formed within the septum and the Triceps muscle.
Clinical Relevance:
The described musculotendinous arcades over the ulnar nerve are primary sites of compression that would necessitate exploration and release in treatment of
cubital tunnel syndrome.
Brain Derived Neurotrophic Factor (BDNF) Mediates Accelerated Nerve Regeneration in
Response to Brief (1hr) Low Frequency Electrical Stimulation of the Surgically Repaired Nerve
Institution where the work was prepared: Tessa Gordon, Edmonton, AB, Canada
Tessa Gordon, PhD1; Neil Tyreman1; L. Pettersson2; Valerie Verge, PhD2; (1)University of Alberta, (2)University of Saskatchewan
We demonstrated previously that electrical stimulation for 1hr (ES) accelerates axon outgrowth after surgical repair of injured peripheral nerves in conjunction with early
and pronounced expression of mRNA coding for BDNF and its cognate receptor trkB in the stimulated motoneurons. However, it is not known whether this BDNF and
trkB receptor expression is critical to the enhanced regeneration in response to ES. Our work showing that endogenous BDNF is required for the induction of a robust
cell body response after nerve injury in motor and sensory neurons suggests this may be the case. In the current study we therefore asked whether BDNF is a key component of the cell body response that mediates the accelerated axon outgrowth in response to ES. We cut and surgically repaired the femoral nerve in Sprague Dawley
rats with 11-0 surgical silk under deep surgical anesthesia. The proximal nerve stump was electrically stimulated for 1 hr with 20Hz continuous bipolar pulses with and
without intra-thecal infusion of anti-BDNF at 1.5mg/ml. The anti-BDNF used was a selective function blocking antibody against BDNF to immunoneutralize BDNF. Three
weeks later, retrograde dyes fluorogold and rubyred, were applied to the branches of the femoral nerve. The dyes were alternated between rats to backlabel the motoneurons that had regenerated their axons down the appropriate muscle and inappropriate cutaneous branches of the femoral nerve. A total of 332 ± 23.1 (mean ± SE)
motoneurons were found to regenerate their axons over the 25 mm distance in the 3 weeks since the femoral nerve repair and ES, a number that corresponded to the
entire motoneuron pool and significantly more than the 204 ± 13 motoneurons that regenerated after ES and administration of anti-BDNF. The anti-BDNF did not affect
the preferential motor reinnervation effected by the ES – i.e. the motoneurons regenerating their axons preferentially into motor pathways vs sensory pathways (218 ±
20 and 78 ± 6 after ES + anti-BDNF; and 108 ± 26 and 76 ± 23 after ES + saline). The anti-BDNF also did not significantly impact on the small number of motoneurons that regenerated their axons down both pathways (20 ± 4 after ES + anti-BDNF versus 35 ± 13 after ES + Saline). These data provide direct evidence for a key
role of BDNF in mediating the effect of ES of accelerating axonal regeneration into appropriate pathways. Grateful thanks to the CIHR for their support of this research.
104
Otfrid Foerster (1873 – 1941) – a Widely Unrecognized Self-taught Pioneer
of Reconstructive Peripheral Nerve Surgery
Andreas Gohritz1; A. Lee Dellon, MD2; Peter M. Vogt1; (1)Hannover Medical School, (2)Johns Hopkins University
Introduction:
The German neurologiost Otfried Foerster (1873-1941) became a self-taught neurological surgeon during and after WW 1 and thus played a critical role for
the development of modern peripheral nerve reconstruction which has largely been overlooked in our historical heritage.
Objective:
This paper reminds of the life and work of this extraordinary man with special emphasis on his numerable innovations regarding peripheral nerve restoration.
Results:
Best known for discovering dermatomes, Foerster published over 300 articles on the whole nervous system. His activities were severely restricted by the Nazis
because of his wife’s Jewish ancestry and as he was Lenin’s personal physician after his stroke over one year in Russia. He died from tuberculosis in 1941.
During WW 1 Foerster was confronted by thousands of nerve injuries and the poor results and lack of interest of his surgical collegues (“I thought I could do
no worse”) led him to perform neurolysis and nerve repairs himself under emergency conditions. He pioneered grafting of nerve defects by small skin nerves
such as the sural nerve and used intraplexal neurotisations and performed transfers of the pectoral nerves, the subscapular, thoracic longus and thoracodorsal
nerve in brachial plexus injuries. The experience of 4748 peripheral nerve injuries, treated under his guidance until 1918, formed a fundament of modern
nerve reconstruction. Foerster already recognized and used the potential of cortical reorganization, recently re-discovered as “brain plasticity”, to improve
peripheral nerve recovery.
Conclusion:
Despite personal tragedies, professional depreciation and political discrimination, Foerster was an eminent clinical physician and scientist whose innovative
spirit is still a role model for everyone dedicated to peripheral nerve reconstruction.
105
ASPN Scientific Paper Session D
Transplanted Donor Derived Bone Marrow Stromal Cells Engraft Locally
and Systemically when Augmenting the Regeneration of Peripheral Nerve Defects
William Duggan, MD; Aleksandra Klimczak, PhD; Dileep Nair, MD; James Gatherwright; Maria Siemionow, MD, PhD, DSc; Cleveland Clinic
Purpose:
Nerve grafting has been the most widely accepted surgical intervention for the repair of peripheral nerve defects. Such interventions have been associated with varying
degrees of donor site morbidity, which has led to the search for alternative methods of peripheral nerve repair. This study was performed to assess whether supportive
therapy with bone marrow stromal cells (BMSC) will contribute to nerve regeneration and to asses the fate of locally transplanted BMSCs.
Methods:
54 epineural tubes were transplanted in 3 experimental groups (18 animals in each group). Group 1 was control saline, Group 2 isogenic BMSCs and Group 3 allogenic BMSCs. In Groups 2 and 3, BMSCs were stained with PKH-dye before delivering 2.5-3.0 x 106 cells into the transplanted epineural tube. Evaluations were performed at 6, 12, 18 and 24 weeks post-transplant. PKH staining facilitated our assessment of donor-origin cell (RT1a) migration and engraftment. Flow cytometry assessed
for the presence of donor-origin cells (RT1a) in the bone marrow compartment of the allogenic BMSC recipients. Cell migration results were correlated with axonal countings and immunostaining with nerve growth factors: NGF, Laminin B2, GFAP, VEGF and Von Willebrand Factor for the assessment of the expression of neurotrophic factors and regenerative potential of transplanted BMSCs.
Results:
Engraftment of donor-origin cells (RT1a) into the bone marrow compartment of allogenic BMSCs recipient was confirmed by the presence of 1.87% (RT1a) positive cells
at 12 weeks and 3.33% (RT1a) positive cells at 24 weeks post transplant. Donor-origin cells (RT1a) were detected in the lymphoid organs of the nerve allograft recipients.
In groups 2 and 3, PKH positive cells in addition to neurotrophic factors were found in the transplanted tubes. Group 2 showed a higher number of regenerated axons
(90.6 ± 26.9) compared to Group 1 (71.4 ± 3.0) and 3 (76.4 ± 5.4). 18 weeks post transplant isogenic cells (Group 2) expressed neurotrophic factors in the distal portion of the transplanted nerve in contrast to the allogenic group (Group 3) in which neurotrophic factors were expressed in the middle portion of the transplanted nerve.
NGF-staining with PKH-staining confirmed that neuronal differentiation of BMSCs.
Conclusion:
Co-transplantation of BMSCs within epineural tubes enhanced nerve regeneration of peripheral nerve defects and confirmed the regenerative potential of BMSCs through
their differentiation into neural tissue. The regenerative potential of BMSCs was confirmed locally as well as systemically by the presence of donor-origin cells in the lymphoid organs of recipients.
The Clock Face Guide to Peroneal Intraneural Ganglion Cysts: Critical “Times”
and Sites for Accurate Diagnosis
Robert J. Spinner, MD1; Gauri Luthra, BA2; Nicholas M. Desy, BSc3; Meredith L. Anderson, MD1; Kimberly Amrami1; (1)Mayo Clinic, (2)Mayo Medical School,
(3)McGill University School of Medicine
Introduction:
For over 100 years, peroneal intraneural ganglion cysts have been considered curiosities. Because of their relative rarity and physicians’ (radiologists and surgeons) inexperience with them and their complexity, they are frequently misdiagnosed and joint communications are not appreciated preoperatively or intraoperatively. As a result,
outcomes have been suboptimal and recurrences are common. We believe that the consistent anatomy of the common peroneal nerve (CPN) and its branches can be
exploited to identify constant MRI patterns in peroneal intraneural ganglion cysts that will clarify controversies regarding their pathogenesis and treatment.
MRIs of patients with peroneal intraneural and extraneural ganglion cysts were compared to those with normal knees (n = 25 in each of the 3 groups). Using conventional axial images (all interpreted as left-sided), the position of the CPN and intraneural or extraneural cyst was determined relative to standard bony landmarks with a symbolic clock face.
Results:
In all patients the CPN could be seen between 4 and 5 o’clock at the mid-portion of the fibular head. In patients with intraneural cysts, a single axial image at this level
could reliably demonstrate cyst within both the CPN (4 - 5 o’clock) and the articular branch-superior tibiofibular joint connection (11 and 12 o’clock); cyst within the transverse limb of the articular branch was seen at the mid-portion of the fibular neck (12 - 2 o’clock). Extraneural cysts arose from more superior joint connections; their epicenters varied around the clock face without a consistent pattern. There was no significant difference between the visual and template assessment of clock face positions.
Conclusions:
This technique can provide rapid and reproducible information for diagnosis, pathogenesis and treatment planning.
Toward a Biotic-Abiotic Peripheral Nerve Interface
Melanie G. Urbanchek, MS, PhD; Lisa M. Larkin; Brent M. Egeland, MD; William M. Kuzon Jr, MD, PhD; David C. Martin; Paul S. Cederna, MD; University of Michigan
Our purpose was to develop an invivo interface for coupling amputee peripheral nerve to prosthetic devices. Once implanted, each interface contained the transected native peripheral nerve
stump, a bio-scaffold with cultured myoblasts, and a permeable synthetic container. The bio-scaffold was either polymerized with poly (3,4-ethylenedioxythiophene) (PEDOT) or not. We tested the concept that transected peripheral nerves regenerate within an invivo interface containing myoblasts and successfully reinnervate the maturing myoblasts in the presence or absence of
a bio-synthetic electrically conductive material, PEDOT.
The interface with PEDOT (PDot+, n=3) or without PEDOT (PDot-, n=7) were implanted in an invivo rat peroneal nerve transection model. Primary myoblasts were cultured for 14 days
prior to implantation as a component of the 2cm long permeable silicone tube interface. After closure, recovery progressed for 95 days prior to nerve conduction testing and harvest for
histological evaluation.
Preliminary tests verified myoblasts grew successfully on both the bio-scaffold and the bio-scaffold polymerized with PEDOT. Cells counts showed no difference in cell viability (98%) across
the 2 conditions and more live cells at day 7 (186%) than at day 4 (p<0.05). Multinucleated myocytes were observed on all plates. By day 14, myoblasts had formed contracting myotubes
by visual confirmation and desmin staining.
Interface implantation results show small but more mature muscle fibers, regenerated myelinated axons, collagen fibers, and vascularity both the PDot+ and PDot- interface groups. Muscle
cells were grouped together in fascicles and bundles. Many regenerating axons were in close approximation to PEDOT in the PDot+ group. A robust presence of PEDOT was seen within the PDot+ interfaces even after an implant recovery of 114 days though many macrophage were seen in both the PDot+ and PDot- interfaces. Nerve conduction and muscle action
potentials were confirmed within Dot+ and Dot- interfaces, suggestive of synaptogenesis and muscle fiber reinnervation.
We confirmed that transected peripheral nerves regenerate within an invivo interface containing myoblasts in the presence or absence of a bio-synthetic electrically conductive material,
PEDOT. Additional histological work is in progress to verify axons successfully form neuromuscular junctions. These data support the concept that an invivo peripheral nerve coupling interface is biologically possible.
The views expressed in this work are those of the authors and do not necessarily reflect official Army policy. This work was supported by the Department of Defense Multidisciplinary
University Research Initiative (MURI) program administered by the Army Research Office under grant W911NF0610218.
106
Cortical Plasticity Following Median Nerve Transection Using 3T fMRI
Seth Jones, MD; Rupeng Li; Christopher Pawela; Younghoon Cho; Ji-Geng Yan; James Hyde; Hani Matloub; Medical College of Wisconsin
Introduction:
We attempt to derive a model for examining the brain plasticity in peripheral nerve injuries and providing clinical correlates using functional MRI technology
– a non invasive method of examining dynamic brain activity.
Methods:
Acute plasticity model – 5 SD rats had the median nerve transected on the right side and an electrode was placed on the proximal end. The left side served as
an internal control and the left side brachial plexus was exposed and an electrode was placed on the left median nerve (intact). Sub-acute (1-30 days) plasticity model – 3 SD rats had the median nerve of the right forepaw transected. Fourteen days following right median nerve transection, the rat underwent surgical placement of 4 electrodes. The left forepaw served as an internal control. Electrodes were placed on the intact left ulnar and median nerves, intact right
ulnar nerve, and proximal end of the cut right median nerve. The rat underwent a set stimulation protocol and imaged using fMRI at 9.4T.
Results:
Fig. 1a displays the representation of the BOLD signal observed when the right transected median nerve was stimulated proximal to the cut immediately after the
cut was made. Compared to stimulation of the intact side (Fig. 1b), we see that there is no signal in the sensory (S1FL) region on the contralateral side. When the
proximal end of the cut nerve is stimulated 2 weeks later the cortical BOLD signal response (Fig. 1c) is noticeably less than the left intact median nerve (control) (Fig.
1d). The BOLD signal responses from left side nerve stimulation (control) show an expected signal in the right cortex corresponding to the sensory of the rat left
forepaw (Fig. 1d). These were considered normal. There is an increase in the cortical representation of the right ulnar nerve with stimulation (Fig. 1e) 2 weeks after
the right median nerve was cut. As expected, the signal is stronger and more extensive when compared to the representation of the contralateral intact ulnar nerve
(control) (Fig. 1f).
Discussion:
This model demonstrates acute and sub-acute plasticity that occurs within the brain after median nerve transection.
Skin Derived Stem Cells as a Source of Schwann Cells for Repair of the Chronically Denervated Nerve
Sarah K. Walsh, BSc1; T. Gordon2; Rajiv Midha1; (1)University of Calgary, (2)University of Alberta
In previous work, we isolated clones of progenitor cells from the rodent dermis that showed the ability to differentiate in vitro into GFAP/S-100? positive Schwann
cells (SCs) upon supplementation with forskolin and heregulin 1?. These cells, termed skin-derived precursors (SKPs) also differentiate into SCs in response to the
milieu of the regenerating nerve in vivo and survive in considerable numbers for at least 8 weeks following microinjection into both an acutely and chronically denervated nerve following microinjection. Since denervated host SCs progressively lose their growth supportive capacity after nerve injury, we sought to use SKP
derived Schwann cells (SKP-SCs) as a source of replacement SCs that would support enhanced nerve regeneration after transplantation into peripheral nerve. To
this end, we used SKP-SCs to supplement an acellular (freeze-thawed) nerve graft bridging a 12 mm gap created in the sciatic nerve. The grafts were immediately microinjected with culture media, SKP-SCs, or SCs. Morphometrical measurements of cell-treated nerve segments after 8 weeks survival showed significantly
improved regeneration indices as compared to diluent controls. Also, CMAP amplitude and nerve conduction velocity in SKP-treated grafts recovered to autograft
levels (81.6% and 93.9%, respectively of autograft) whereas media treated animals recovered to 32.4% and 64.7% of autograft. We next examined the contribution of SKPs in the common scenario of delayed nerve repair. In stage 1 surgeries, the tibial nerve of adult Lewis rats was transected 1 mm distal to the sciatic trifurcation and capped to prevent reinnervation. After 12 weeks, at Stage 2 surgery, the now chronically denervated distal tibial nerve was repaired by cross-reinnervation with a freshly cut proximal stump of the common peroneal nerve. SKP-SCs (or control media) were delivered distal to the repair site and animals were
recovered an additional 10 weeks. Control animals received an immediate repair using the above cross suture method. After 10 weeks, we observed recovery of
CMAP amplitude in SKP-SC treated animals (8.41±0.84 mV) that approached the level of immediate repair group (13.02±1.34 mV), whereas media controls
exhibited significantly poorer recovery (3.17±0.7 mV). Similarly, wet muscle weights were significantly improved in the SKP-SC treated group versus media controls. Morphometrical parameters, muscle reinnervation and retrogradely labeled motoneuron counts are presently undergoing evaluation. We therefore conclude
that SKPs represent an easily accessible, autologous source of stem cells for transplantation therapies which act as functional Schwann cells and which show considerable promise in improving regeneration following repair of chronic nerve injury.
107
Ischemic Conditions Result in Minimal GFAP Expression in Satellite Cells of the Dorsal Root Ganglion
Krzysztof Siemionow, MD; Grzegorz Brzezicki; Aleksandra Klimczak; Maria Siemionow; Robert McLain; Cleveland Clinic
Background:
Satellite cells(SC) are neuroglial cells that closely interact with nerve cells of the dorsal root ganglion(DRG).The role of SC remains unknown.Glial Fibrillary
Acidic Protein(GFAP) is the principal intermediate filament in mature astrocytes.GFAP expression increases in response to CNS ischemia and injury. Loss of
GFAP impaired Schwann cell proliferation and delayed nerve regeneration after injury.The objective of this study was to identify the effects of ischemia on GFAP
expression in SC of the DRG at various time points.
Methods:
145 rats were used.A hemilaminectomy was performed, five distinct procedures at the left L5 DRG were investigated:1)Group I,the ischemia group,in which the L5
root was tightly ligated proximal to the DRG with chromic-gut;2) Group II,the ischemia group,in which the L5 root was tightly ligated distal to the DRG with chromicgut;3)Group III,the ischemia group,in which the L5 root was tightly ligated proximal and distal to the DRG with chromic-gut;4)Group IV,the inflammation group,in
which fragments of chromic-gut suture were laid adjacent to the DRG;5)Group V,the sham group,in which a hemilaminectomy exposing the DRG was performed.All
wounds were then closed in standard fashion.DRGs were harvested at 4hrs,6hrs,24hrs,48hrs,72hrs,and 7 days post-operatively.The contralateral DRG remained
unexposed and served as an internal control.The harvested DRG were analyzed using light microscopy for immunoreactivity using GFAP monoclonal antibody.
Results:
290 DRG were harvested and available for analysis.Naïve controls did not express GFAP in either nerve cells or satellite cells.Nerve cells did not express GFAP
at any time point.Group I,proximally ligated DRG did not express GFAP at any time point.Group II,satellite cells in the distally ligated DRG did not express
GFAP until day 7 post injury.Group III,the proximally and distally ligated DRG did not express GFAP at any time point.Group IV,the inflammation group,30%
of satellite cells demonstrated GFAP expression at 6hrs, 85% at 24hrs,100 % at 48hrs,72hrs,and 7 days.Group V,the sham group,GFAP expression was
observed in 0% of satellite cells at 6hrs,5% at 24hrs,85% at 48hrs,and 100% at 72hrs and 7 days.In the contralateral undisturbed DRGs of all groups,<5% of
satellite cells expressed GFAP at 4hr and 6hrs,20% at 24hrs,30% at 48hrs,and 100% at 72hrs and 7 days.
Conclusions:
Satellite cells are the primary source of GFAP in the DRG under inflammatory conditions.Under ischemic conditions the expression of GFAP by SC is undetectable by
immunohistochemistry until day 7.Satellite cells respond differently to ischemic conditions than glial cells of the CNS and SC may represent a distinct cell population.
Hand Prehension Recovery After Brachial Plexus Avulsion by Means of
Full-length Phrenic Nerve Transfer via Endoscopic Thoracic Surgery
Institution where the work was prepared: Huashan Hospital, Shanghai, China
Wen-Dong Xu, MD, PhD; Yan-Qun Qiu; Jiu-Zhou Lu; Lei Xu; Jian-Guang Xu; Yu-Dong Gu; Huashan Hospital,Fudan University
Objective:
The functional recovery of hand prehension still remains an unsolved problem nowadays. The authors conducted a prospective study to provide a new method
to solve it.
Methods:
In the present study 3 patients underwent a new procedure, during which the full-length phrenic nerve was transferred to the medial root of median nerve by
the technique of endoscopic thoracic surgery support.
Results:
All three Patients were followed up for a postoperative period more than 3 years and resulted well (The power of the flexor pollicis longus and the flexor digitorum profundus of all four fingers was Grade 3-4 of 5 and no symptoms of respiratory insufficiency occurred.).
Conclusions:
It is proved that the neurotization of phrenic nerve to the medial root of median nerve via endoscopic thoracic surgery is a feasible way for early hand prehension recovery.
Schwann Cell Migration into Peripheral Nerve Allografts: A Longitudinal Assessment
Institution where the work was prepared: Washington Unviersity in St Louis School of Medicine, Saint Louis, MO, USA
Elizabeth L. Whitlock, BA; Terence M. Myckatyn, MD; Alice Y. Tong; Andrew X. Yee, BS; Ying Yan, MD, PhD; Amy M. Moore; Christina M. Magill, MD;
Susan E. Mackinnon, MD; Washington University School of Medicine
Purpose:
Although Schwann cell (SC) migration is likely the limiting factor in shortening the duration of immunosuppression following peripheral nerve allograft placement, SC migratory behavior is still poorly understood. Endpoint imaging of explanted grafts provides some information, but repeated direct visualization, utilizing transgenic mice and serial live imaging, may yield more detailed information on SC behavior over time.
Methods:
Mice with GFP under the control of the S100 Schwann cell promoter were engrafted with allogeneic, nonfluorescent 5 mm sciatic nerve grafts and received
either FK-506 (tacrolimus) or T-cell costimulation blockade to provide immunosuppression. Three harvest endpoints were selected (6, 10 and 15 weeks); mice
receiving FK-506 were then either given a ten-day immunosuppressant hiatus or maintained on immunosuppression until sacrifice. Serial live imaging of grafts
at postoperative weeks 3, 6, 9, 12 and 15 allowed us to track migration of fluorescent SCs into non-fluorescent grafts. Rejection response was quantitated with
ELIspot for ?-interferon and segmental Western blot of explanted nerves for activated caspase 3. Explanted grafts were evaluated for immunohistochemical
staining patterns and native GFP fluorescence, which allowed us to differentiate graft from host SCs.
Results:
Under immunosuppression, substantial host SC migration into the graft occurs early (within three weeks) despite apparent maintenance of donor SCs.
Additionally, there was prominent migration of graft SCs into local surrounding host nerve. Even at the 15-week endpoint, graft fluorescence was decreased
relative to surrounding host nerve and donor cells persisted within the graft, demonstrating that at this late endpoint full repopulation of the graft with host SCs
did not occur in the presence of immunosuppression. In mice receiving FK-506, a ten-day immunosuppressant hiatus prior to sacrifice resulted in elevated levels of activated caspase 3 proximal to, distal to, and within the graft. This indicates that rejection of donor cells was occurring in all three regions, consistent
with migrational patterns observed with immunohistochemistry.
Conclusions:
These findings in the allograft situation are consistent with a previously described isograft model of SC behavior in which early intermingling of graft and host SCs
occurs, followed by a period of migrational stability. Discontinuation of immunosuppression, with subsequent rejection of graft SCs, is required to stimulate further
repopulation with host cells and achieve nonimmunogenicity. Future work may focus on methods to mitigate the harmful effects of sudden SC rejection when immunosuppression is discontinued, including gradual withdrawal of immunosuppressants or partial repopulation of allografts with host SCs prior to implantation.
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Peripherally versus centrally derived glial cell line-derived neurotrophic factor (GDNF)
provides a physiologic stimulus to regenerating motor and sensory nerves
Institution where the work was prepared: Washington University School of Medicine, St. Louis, MO, USA
Christina M. Magill1; Amy M. Moore1; Ying Yan1; Andrew Yee1; Alice Y. Tong1; Daniel A. Hunter1; Ayato Hiyashi, MD, PhD>2; Alexander Parsadanian, PhD3;
Terence M. Myckatyn, MD3; (1)Washington University School of Medicine, (2)Division of Plastic and Reconstructive Surgery, (3)Washington University in St. Louis
Objective:
Glial Cell Line-Derived Neurotrophic Factor (GDNF) has been shown to have potent survival effects on central and peripheral neuron populations. Motoneurons are especially sensitive to GDNF, and GDNF may affect peripheral nerve regeneration and improve functional recovery following otherwise devastating nerve injury. We examine the effects of centrally vs. peripherally derived GDNF following either a sciatic nerve or saphenous nerve crush injury in mice that overexpress GDNF in the CNS
(GFAP-GDNF) or in the muscle target (Myo-GDNF).
Methods:
Adult mice [GFAP-GDNF and Myo-GDNF single transgenic animals, or cross bred to thy1-YFP(16)] undergo sciatic nerve or saphenous nerve crush and are evaluated following injury with histomorphometric analysis, motoneuron retrograde labeling, transcutaneous imaging, and confocal microscopy of extensor digitorum longus (EDL) muscle whole
mounts to visualize dynamics at the motor endplate. Functional recovery is assessed with muscle force and power measurements of the EDL. Uninjured WT [or single transgenic
thy1-YFP(16)] animals are used as controls.
Results:
Sciatic nerve crush: all animals show complete denervation of motor endplates 1wk after sciatic nerve crush, with Myo-GDNF having greater reinnervation 2wks and 4wks after nerve
crush compared to GFAP-GDNF and WT animals. Histomorphometric analysis of sciatic nerves 1cm distal to the crush site demonstrated a higher number of total nerve fibers in MyoGDNF animals compared to GFAP-GDNF and WT (p<0.05). At 4 wks after injury, Myo-GDNF animals have higher retrograde labeled motoneuron counts than GFAP-GDNF and
WT mice. By 6 wks, all groups show complete motor endplate reinnervation and there is no significant difference in fiber counts between groups; however, Myo-GDNF animals continue to demonstrate higher retrograde labeled motoneuron counts. Muscle force and power measurements showed GFAP-GDNF animals to have impaired functional recovery compared to the Myo-GDNF and WT mice. Saphenous nerve crush: Myo-GDNF and WT animals had a significantly higher rate of saphenous nerve regeneration following injury as
compared to GFAP-GDNF animals, which did not demonstrate complete regeneration.
Conclusions:
Peripheral delivery of GDNF results in earlier reinnervation following both sciatic and saphenous nerve crush injury as compared to central GDNF delivery. The central delivery of GDNF inhibited sensory nerve regeneration. Neurotrophic factors, such as GDNF, may offer new possibilities for the treatment of peripheral nerve injury, but the site of
delivery for these factors must have physiologic efficacy for regenerating nerve fibers.
Patterns of Intraneural Ganglion Cyst Descent
Robert J. Spinner, MD1; Stephen W. Carmichael, PhD1; Huan Wang, MD, PhD1; Thomas J. Parisi, BA2; John A. Skinner1; Kimberly Amrami1; (1)Mayo Clinic,
(2)Mayo Medical School
Introduction:
Based on the principles of the unifying articular theory, predictable patterns of proximal ascent have been described for peroneal and tibial intraneural ganglia in the
knee region. The mechanism underlying distal descent into the terminal braches of the peroneal and tibial nerves has not been previously elucidated. The purpose of this
study is to demonstrate if and when cyst descent distal to the articular branch– joint connection occurs in intraneural ganglia in order to understand directionality of intraneural cyst propagation.
Methods:
In Part I, the clinical records and MRIs of 20 consecutive patients treated at our institution for intraneural ganglia (18 peroneal and two tibial) arising from the superior
tibiofibular joint were retrospectively analyzed. These patients underwent cyst decompression and disconnection of the articular branch. Five of these patients developed
symptomatic cyst recurrence after cyst decompression without articular branch disconnection was done elsewhere prior to our intervention. In Part II, five additional patients
with intraneural ganglia (three peroneal and two tibial) treated at other institutions without disconnection of the articular branch were compared. These patients in Parts I
and II demonstrated ascent of intraneural cyst to differing degrees (12 had evidence of sciatic nerve cross-over). In addition, all of these patients demonstrated previously unrecognized MRI evidence of intraneural cyst extending distally below the level of the articular branch to the joint of origin: cyst within the proximal most portions of
the deep and superficial peroneal branches in peroneal intraneural ganglia and descending tibial branches in tibial intraneural ganglia. The patients in Part I had complete resolution of their cysts at follow-up MRI examination 1 year postoperatively. The patients in Part II had intraneural recurrences postoperatively within the articular
branch, the parent nerve and the terminal branches, although in three cases they were subclinical.
Conclusions.
We demonstrate that cyst descent distal to the take-off of the articular branch to the joint of origin occurs regularly in patients with peroneal and tibial intraneural ganglia. We believe that parent terminal branch descent follows ascent up the articular branch from an affected joint of origin. This mechanism for bidirectional flow explains
cyst within terminal branches of the peroneal and tibial nerves and is dependent on pressure fluxes and resistances. This new pattern is consistent with principles previously described in the articular theory, is generalizable to other intraneural ganglia arising from joints, and has important implications for pathogenesis and treatment of
these intraneural cysts.
Minimally Invasive Peripheral Nerve Surgery – What is it and Why?
Ivica Ducic, MD, PhD; Georgetown University Hospital
Introduction:
There is an overall trend with advances in new surgical techniques to improve patient’s safety and outcomes, as well as to contribute to cost-effectiveness of the procedures. Many
respective specialties successfully applied laparoscopic or robotic-assisted abdominal, thoracic and pelvic procedures, minimally invasive spine surgery, etc. With respect to peripheral nerve surgery, beyond endoscopic carpal tunnel, still to be proven cubital tunnel surgery and robotic cavernous nerve reconstruction, not much progress was made in the
past 15-20 years. We looked at the current opportunities for expanding “minimally invasive” applications to peripheral nerve surgery that would be safe, cost effective and simple to reproduce.
Methods:
The approach for current common peripheral nerve surgery procedures was evaluated and those where a minimally invasive application was possible were selected. An
average shortening of incision length, effect on operative time, patient incisional per-operative discomfort, patient’s satisfaction/preference with the new incision and perioperative morbitidy were evaluated. Minimally invasive approach was applied using simple, readily available lighted retractor for neurolysis/decompression (but not excisions or reconstructions) of (at): zygomatic-temporal and auriculotemporal nerve (temple), greater occipital nerve (occipital area), brachial plexus (supraclavicular area),
ulnar nerve (elbow), radial nerve (forearm; upper arm), median nerve (forearm), LFCN (hip), peroneal nerve (groin), peroneal nerves (fibular neck, lateral calf), tibial and
inner ankle nerves (ankle). Similarily, partial knee and hip denervations for knee and groin pain were assisted with similar method, respectively.
Results:
The average length of “minimally invasive” incision was 3.9 ± 0.6 cm (range 3.1 – 6.1 cm), while the average reduction of the length of each procedure’s incision was
51% (range 30%-75%; p<0.001). Patients responded that minimal incision approach was less painful then they anticipated (69%), as expected (29%), and more then
anticipated (2%). By calculating the time that would take to dissect and close (two layers) remaining (average 51 %) of incision in a conventional way, operative time was
shortened by 6-10 minutes. All patients preferred smaller scars (100%, p<0.0001). There were no inadvertent perioperative morbidities using smaller incisions.
Conclusions:
Minimally invasive peripheral nerve surgery applied to the above procedures is safe and cost effective (especially when adding cumulative time saved per multi-procedure day), leading to more patient satisfaction considering less visible permanent scarring. Learning curve is fast with only few cases needed to gain appropriate benefits of the approach. It should be noted that the author does not have any direct or indirect financial interest with industry/equipment used.
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MRI Interpretation Amongst Other Indicators of Malignancy in Peripheral Nerve Sheath Tumors
Justin M. Brown, MD; Noopur Gangopadhyay, MD; Susan E. Mackinnon, MD; Washington University
Purpose:
Although consesus exists that MRI is an inadequate modality for determining aggressiveness for peripheral nerve sheath tumors, radiologists continue to refer
to imaging features as indicators of benignity or malignancy in these lesions. As a result, clinicians often approach these lesions in a more or less agressive
manner consistent with the interpretation. The purpose of this study is examine the relative roles of history, physical examination, imaging and intraoperative
impression in determining the likelihood of malignancy.
Methods:
A retrospective review of 99 patients, 41 male and 57 female ages 9 to 80, who were diagnosed radiographically or clinically with 100 peripheral nerve sheath
tumors of the extremity or plexus was performed. Both MRI interpretations and pathology reports were each categorized as “benign”, “malignant”, “other benign
lesion” or “normal.” In addition to comparing MRI interpretation and pathology report, symptoms and timing of their progression, physical examination, and
intraoperative interpretation were evaluated for their correlation with the final pathology. The symptoms and signs were also evaluated controlling for occurance
at sites of entrapment, size, time to presentation and recurrence.
Results:
Of the 20 pathologically confirmed malignant peripheral nerve sheath tumors, only 6 were disgnosed correctly by MRI. Of the 80 benign lesions, 67 were correctly diagnosed with imaging. We confirmed that radiological indicators of aggressiveness did not prove to be a useful predictors of pathology. Instead, intraoperative impression yielded the most accurate information. Likewise clinical history and examination findings were not distinct between the two groups. The
most significant difference here was the timing of presentation of patients with a peripheral nerve sheath tumor who experienced pain. The presence or absence
of subjective symptoms, neurological signs and examination findings did not differ significantly. The most notable trend indicated that provocative testing was
more likely to be positive at the site of a benign lesion. The only statistically significant predictor was the intraoperative impression, which correctly identified
13 of 20 MPNSTs.
Conclusions:
This study confirms the notion that MRI interpretations should not guide surgical decision-making for these lesions. In fact, none of the above criteria in isolation provided adequate direction for surgical management. Maintaining a high index of suspicion for more dramatic and rapid presentations is warranted. In addition, strongly considering a more aggressive approach in the light of a malignant-appearing lesion discovered during surgery is recommended. Finally, overriding clinical judgement on the basis of a divergent radiological interpretation is strongly discouraged.
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ASPN Scientific Paper Session E
Thalamic White Matter Changes are Associated with Chronic Pain Following
Peripheral Nerve Injury and Surgical Repair
Institution where the work was prepared: University Of Toronto, Toronto, ON, Canada
Keri S. Taylor, BSc; Dimitri J. Anastakis, MD, MEd, MHCM; Karen D. Davis, PhD; University of Toronto
Introduction and Aim:
Development of chronic neurogenic pain following peripheral nerve injury and surgical repair (PNIr) is not uncommon. The aim of this study was to determine whether patients
with chronic neurogenic pain following PNIr exhibit structural brain changes that differ from either PNIr patients with no pain or from healthy control subjects.
Methods:
Our study included 14 PNIr patients without pain (12 male, 2 female; 33 +/- 9yr), 6 PNIr patients with chronic pain (4 male, 2 female; 43 +/- 10yr), and 12 healthy
controls (8 male, 4 female; 42 +/- 10 yr). All patients had sustained a complete median and/or ulnar nerve transection that was surgically repaired at least 1.5yrs prior
to study enrolment. All subjects participated in a battery of sensory and motor tests, nerve conduction studies, and an MRI session that included diffusion tensor imaging
(DTI). DTI was used to assess fractional anisotropy (FA), a quantitative measure of white matter integrity. In order to compare FA values across patients and controls, white
matter regions of interest (ROIs) were selected for the bilateral anterior and posterior insula, primary somatosensory cortex (S1), and thalamus.
Results & Discussion:
The PNIr patients as a whole showed sensory deficits in 2-point discrimination, vibration, touch, and warmth detection (p<0.05), as well as in the shape texture identification (STI)
and grooved pegboard tests (p<0.001). The PNIr patients with chronic pain showed a significantly greater impairment, than PNIr without pain, in vibration detection, STI, the
Southampton hand assessment and grooved pegboard tests (p<0.05). PNIr patients, both with and without pain, had lower FA within the white matter surrounding the right anterior insula and contralateral S1 compared to healthy controls. Patients with pain also had significantly lower FA in the white matter adjacent to the ventral posterior and medial
thalamus compared with healthy controls and PNIr patients with . . .
Understanding T Helper Phenotype in Peripheral Nerve Allograft Survival Using STAT Knockout Mice
Wilson Z. Ray, MD; Nancy Solowski, MD, MS; Daniel A. Hunter; Ying Yang; Andrew Yee; Susan E. Mackinnon; Thomas Tung; Washington University
Purpose:
Peripheral nerve allografts are used to repair neural defects when the defects cannot be primarily repaired and when a nerve autograft is not a viable option. While the
introduction of a peripheral nerve allograft increases the possibilities for nerve repair and functional recovery, patients must undergo an immunosuppressive regimen to
prevent allograft rejection. This immunosuppression carries its own risks. A better understanding of the mechanisms of peripheral nerve allograft survival with treatment
is needed to identify the individual components of the pathways involved and more accurately target immunosuppression in a clinical setting while reducing potentially
dangerous side effects. Our study uses knockout mice deficient in either Stat 4 or Stat 6 genes to define the role of T helper cell phenotype in the promotion of allograft
survival using costimulation blockade and cold preservation.
Methods:
Knockout mice deficient in either Stat 4 or Stat 6 genes underwent sciatic nerve repair with 1 cm peripheral nerve allografts from mice of antigenetically distinct backgrounds and treated with either costimulation-blocking antibodies or cold allograft preservation. These animals were compared with control animals of antigenetically similar background which received untreated peripheral nerve isografts or untreated peripheral nerve allografts. Experimental mice underwent walking tracks to determine
functional recovery. Nerves were harvested after three weeks and histomorphometric analysis of the regenerating nerves was conducted for comparison. Mice also underwent splenocyte harvest for ELIspot analysis at three weeks to evaluate IFNƒ? production to quantify the host immune response.
Results:
Both Stat 4 and Stat 6 knockout mice showed histomorphometric evidence of improved neural regeneration when compared to untreated allograft controls in wild type mice and
were better also than wild-type recipients receiving costimulation blockade. Evaluation by ELISPOT analysis is pending.
Conclusions:
Knockout mice deficient in either Stat 4 or Stat 6 genes have proved to be a valuable tool in further understanding the role of T helper phenotype in allograft survival.
Findings from this study will have important applications in clinical practice and enable us to more accurately target immunosuppressive therapy while reducing potentially dangerous side effects of treatment.
Recovery of Rodent Whisking Function Following Crush, Transection, and Entubulation
Institution where the work was prepared: Massachusetts Eye and Ear Infirmary, Boston, MA, USA
Tessa A. Hadlock, MD1; Jeffrey Kowaleski1; David Lo1; Susan Mackinnon2; James T. Heaton, PhD3; (1)Massachusetts Eye and Ear Infirmary and Harvard Medical
School, (2)Washington University in St. Louis, (3)Massachusetts General Hospital
Introduction:
Rodent models of facial nerve injury provide a mechanism for studying the behavioral correlates of axonal misrouting and multiply terminal axon sprouting. In this study,
we compared recovery of vibrissial function following three types of clinically possible nerve injury, and examined the differences in recovery between lesions occurring
at the main trunk of the facial nerve, versus lesions distal to the trifurcation.
180 adult female Wistar rats underwent implantation of a titanium head fixation device, followed by conditioning to the restraint system and testing apparatus. All groups
(n = 20) underwent left facial nerve exposure. In the sham group, the wound was simply closed. In the experimental groups, the nerve was either double crushed, transected and repaired epineurially, or transected and the proximal and distal stumps suture secured into a silicone tube with a 2 mm gap between stumps. In the denervation control groups, the nerve was transected, and the proximal stump(s) buried to prevent sprouting. For each injury/repair method, lesions were made in the main trunk
in one group, and in each branch distal to the trifurcation in the other group. Facial recovery was then measured on a scheduled basis for the ensuing 1-4 months.
Results:
162 animals remained testable throughout the study period. Data were analyzed for whisking recovery, by averaging the top three highest amplitude whisks, with respect
to amplitude, velocity, and acceleration. Sham animals had normal facial function, and denervation controls experienced no significant recovery. Animals in the crush
groups recovered nearly normal whisking parameters within 25 days, commensurate with our previously published data. The main trunk crush group showed improved
recovery over the distal branch crush group for several days during early recovery, and thereafter showed no significant differences. By week 9, the transection/repair
groups showed evidence of recovery that trended further upward throughout the study period, but with no difference in degree of recovery according to lesion location.
The main trunk entubulation group followed a similar recovery pattern, though the peripheral entubulation group did not reach significant recovery levels by the conclusion of the study period.
Conclusions:
Rodent vibrissial function recovers in a predictable fashion following lesion and repair. Lesion location does not appear to significantly effect recovered whisking parameters,
indicating that midfacial axonal input is likely to be equivalent following either main trunk or peripheral lesioning.
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In Vivo Analysis of a Polyethylene Glycol Hydrogel Nerve Glue
Institution where the work was prepared: Virginia Commonwealth University Health System, Richmond, VA, USA
Jonathan Isaacs, MD; Ivette Klumb, MD; Candice McDaniel, MD; VCU Medical Center
Nerve glue, as a concept, seems to be well accepted and has many advantages over conventional suturing. Fibrin glues, while currently the most popular tool available
for this particular application, have some distinct disadvantages including less than ideal holding strength, occasional inconsistency, and a questionable propensity towards
increased scar tissue. We are interested in alternative nerve glues such as polyethylene glycol hydrogel. This hydrogel, which is nontoxic and bio-combatable, and does
not appear to cause inflammation or adhesions (and may inhibit adhesions), is made by mixing a water-soluble amine solution and a multi-armed polyethylene glycol
based (PEG) solution. Cross-linking results in the formation of a strong semi-adherent gel-like substance. We have previously demonstrated that a commercially available
polyethylene glycol hydrogel sealant (DuraSeal, Confluent Surgical, Inc., Waltham, MA) and a commercially available fibrin glue (Tisseel, Baxter Healthcare Corporation,
Westlake Village, CA) have equivalent biomechanical holding strengths when applied to “repaired” cadaveric nerves (Presented ASPN Annual Meeting, Los Angeles, CA,
2008). In vitro performance of this hydrogel when applied as a nerve glue, however, is not known. The purpose of this study was to basically evaluate this performance.
The sciatic nerves of 30 rats were transected and repaired under operating microscope visualization using two 10-0 nylon sutures and either hydrogel or fibrin glue. After
10 weeks, nerve conduction velocities and muscle contraction forces were evaluated and compared. Average nerve conduction velocity for the fibrin glue was 0.933 m/s.
Average nerve conduction velocity for the hydrogel group was 0.941 m/s. Muscle strength testing revealed the average ratio of experimental to control sides for the fibrin glue group was 0.75 and for the hydrogel group was 0.72. No significant differences (using paired Student’s t-test) were demonstrated between these groups (P >
0.05). Perineural scarring was evaluated histologically at 10 weeks. Longitudinal sections through the repaired nerve demonstrated a significant reduction in scar thickness in the hydrogel group. (P < 0.01, Student’s t-test). Axonal counts were also performed and the ratios of the counts distal and proximal to the repairs were compared.
No significant differences (using paired Student’s t-test) were demonstrated between the two groups (p > 0.05). Based on these results, hydrogel can be considered an
equivalent nerve glue with regards to nerve regeneration when compared to fibrin glue. Although, hydrogel usage was associated with less scar tissue formation, the functional significance of this could not be demonstrated in this animal model.
Differential Neural Input Influences Muscle Fiber Type of In Vivo Tissue Engineered Skeletal Muscle
Melissa E. Melvin, MD; Cynthia L. Marcelo; David L. Brown, MD, FACS; University of Michigan
Introduction:
Functional tissue-engineered skeletal muscle will benefit all patients with muscle loss. Our lab has previously developed an in vivo model for functional engineered skeletal muscle with its own axial blood supply and nerve input. Most recent studies showed that the neurotized constructs produced contractile forces 5X higher than constructs
without nerve input. In addition, we were able to demonstrate both histologically and physiologically that neuromuscular junctions formed between the nerves and the
engineered muscle. As muscle function is largely guided by muscle fiber type, we sought to determine the expression of the various myosin isoforms (and therefore fiber
type) in engineered skeletal muscle, and to examine whether muscle fiber type can be influenced by varying the type of neural input to the constructs.
Methods:
As in our previously-established model, the spontaneous development of angiogenesis is induced around a vascular pedicle in adult rats. This forms the platform onto
which cultured myoblasts (derived from adult rat fast- or slow-twitch muscles) are seeded, and subsequently develop into mature, functioning muscle constructs in vivo. The
constructs were neurotized with motor nerves which previously supplied either a fast- or slow-twitch muscle. After 4 weeks of maturation in vivo, the constructs were analyzed for the presence of myosin Type I (slow-twitch) and Type II (fast-twitch) by immuno-histochemical staining, and gel electrophoresis. Experimental groups included
constructs seeded with myoblasts derived from soleus (slow-twitch) or EDL (fast-twitch) muscles, which were then innervated (or cross-innervated) with their respective
nerves.
Results:
All constructs demonstrated excellent muscle development with incorporation of the motor nerve, when present. Interestingly, gel electrophoresis showed a mix of myosin
types I and II in the soleus-derived constructs. Immunostaining with monoclonal antibodies against slow- and fast-twitch myosin showed a predominance of type II myosin
in all soleus-derived muscle constructs, regardless of neural input. Results of testing of EDL-derived constructs, as well as PCR data, are pending at the time of this abstract.
Conclusion:
Regardless of neural input, most constructs showed a mix of myosin Types I and II on gel electrophoresis, and a predominance of Type II fibers on IHC staining. This suggests that
the constructs are influenced by neural input. Concurrent with our previous findings that neurotization of muscle constructs significantly increases contractile forces, these results
appear to show that neural input affects fiber type in in-vivo tissue engineered muscle.
Poly(3,4-Ethylenedioxythiophene) PEDOT Bioengineered Constructs Can Deliver Afferent SNAPs With High Efficiency
Brent M. Egeland, MD; Melaine G. Urbanchek, PhD; Sarah M. Richardson-Burns, PhD; William M. Kuzon, MD, PhD; Daryl R. Kipke, PhD; David C. Martin, PhD; Paul
S. Cederna, MD; University of Michigan
Objective:
Coordinated closed loop sensory communication with the central nervous system is the greatest challenge remaining in the development and deployment of advanced
prosthetic limbs. Not only is sensory protection necessary, but near instantaneous feedback is necessary to control prosthetic-based electromechanical actuators during
fine motor tasks. A high fidelity, durable, peripheral nerve bioelectrical interface capable of this task remains elusive. We have previously described the in vivo electrophysiologic properties of poly 3,4-ethylene-dioxythiophene (PEDOT) on acellularized muscle scaffolds (ACM-PEDOT) in an efferent motor interface setting, where its properties approach those of intact nerve. We hypothesize that this novel bioengineered peripheral nervous system (PNS) prosthetic interface is capable of initiating microvolt
afferent sensory nerve action potentials (SNAPs), where technical factors and signal to noise issues assume greater importance.
Methods:
In vivo construct conductivity was tested using a rat hind limb sural nerve model. Interface material test groups included: 1) acellularized muscle (ACM), 2) ACM treated
with PEDOT polymerization reagent Iron (III) Chloride (ACM-Fe), and 3) ACM-PEDOT. Controls included: 1) intact nerve (Intact) and 2) autogenous nerve grafts (Nerve
Graft), and 3) unreconstructed nerve gaps (Nerve Gap). All constructs measured 20mm in length. N=5 for each group. Epineural coaptations were performed proximally and distally. Antidromic sensory studies were performed acutely by stimulating the sural nerve proximal to the construct and recording SNAPs distally. Nerve conduction velocity (NCV), latency and amplitude were recorded. ANOVA with post-hoc analysis was performed for each measured outcome with significance at p<0.05.
Results:
SNAP NCV results (Figure) demonstrate that 20mm ACM-PEDOT constructs transmit a discrete microvolt nerve depolarization with an amplitude of 35.78±27.56 µV and
latency of 2.68±0.36 ms when stimulated with a 1.22±0.29 mA optimized current. This performance does not differ from intact nerve (43.29±18.28 µV, 2.78±0.23 ms,
0.84±1.12 mA, respectively), and outperforms 20mm nerve autografts, which required statistically more stimulation (8.08±3.22 mA) (worse signal to noise ratio). ACMPEDOT shows increased NCV (23.06±4.67 m/s) compared with intact nerve (16.38±1.35 m/s). ACM and ACM-Fe interfaces and nerve gaps were non-conductive.
Conclusions:
ACM-PEDOT biosynthetic peripheral nerve interfaces transmit physiologic afferent SNAPs in vivo with high efficiency, electrically outperforming acute nerve autografts.
This efficiency makes the ACM-PEDOT construct an ideal interface model for afferent sensory signal delivery from a prosthetic, and may allow the deployment of a biologically-derived bidirectional closed loop PNS interface.
112
The Feasibility of Using Side-to-Side Nerve Grafts to “Protect” Chronically
Denervated Nerve Pathways During Axon Regeneration
Institution where the work was prepared: University of Alberta, Edmonton, AB, Canada
Adil Ladak, MD; P. Schembri, MD; N. Tyreman; J. Olson, MD; Tessa Gordon, PhD; University of Alberta
The goal in the surgical repair of peripheral nerve injuries is the precise union of the proximal and distal stumps of the transected nerve such that optimal nerve
function is achieved. It has been established that there is a narrow window of opportunity for axonal regeneration so that with high ulnar nerve lacerations for
example, long-term neuronal axotomy and chronic denervation of distal nerve stumps will progressively reduce regenerative potential to almost zero. In this
study we used side-to-side nerve bridges to the distal nerve stump as a means to “protect” chronically denervated distal nerve stumps. Sprague Dawley rats
(n=8) were divided into 2 groups, both of which underwent a unilateral transection of the common peroneal (CP) nerve. In group 1 (the unprotected group),
the ends of the severed nerve were sutured back to muscle to prevent reinnervation. In group 2 (experimental group), in addition to suturing the ends of the CP
nerve, three side-to-side nerve bridges (obtained from the contralateral CP nerve) were used to join the tibial (TIB) nerve to the distal stump of the CP nerve to
protect the chronically denervated CP nerve. Both groups were left to convalesce for 4 months and then the severed ends of the CP nerve in both groups were
surgically repaired via primary suture coaptation. The rats were again allowed to convalesce for 6 months, at which time back-labeling was performed using
fluorescent retrograde dyes to quantify axonal regeneration. The mean number of axons (± SE) regenerating through the CP nerve in the protected group (132.2
± 28) was significantly higher than in the unprotected group (76.7 ± 33). From previously published work (Sulaiman, 2000), it is known that regeneration
through chronically denervated nerve approaches only 20% of normal. With protecting the distal stump of the chronically denervated nerve, we have demonstrated regenerated axon counts approximately 40% of normal. In addition to axon counts, the tibialis anterior muscle weights were obtained and the mean
muscle weight (± SE) of the protected group (363.5 ± 21 g) was significantly higher than in the unprotected group (219.3 ± 29 g). Our data demonstrate the
feasibility of using multiple side-to-side nerve bridges to maintain the integrity of a chronically denervated nerve and promote greater functional reinnervation
following primary nerve coaptation of a chronically denervated nerve.
The Influence of BFGF and/or NGF in the Outcome of End-to-Side Neurorrhaphy
in the Rat-Sciatic-Nerve Experimental Model
Institution where the work was prepared: General Hospital , Athens, Greece
Eleni Ntouvali, MD1; Spyridon Deftereos, MD2; Theodoros Filippidis, MD3; Michalis Sideris4; Grigorios Panagopoulos, MD2; Apostolos Papalois, PhD4;
Panagiotis Athanasiou Kinnas, MD1; (1)General Hospital “Asclepeion Voulas”, (2)General Hospital “G. Gennimatas”, (3)MICROMEDICA, (4)ELPEN
Pharmaceuticals
Purpose:
The aim of this study was to investigate the short-term results of end-to-side neurorraphy of the common peroneal nerve (CPN) to the tibial nerve (TN) in rats,after
intraoperative subepineurial administration of bFGF and/or NGF.Materials:Five(5) groups of adult male Wistar rats,each comprising 25 animals,were
studied:I.End-to-side neurorrhaphy[4 groups: A(bFGF 20ng),B(NGF 25ng),C(normal saline),X(bFGF 20ng + NGF 25ng)] and II.Negative control group(G).
Methods:
In groups A,B and X,the right CPN was sharply divided at a distance of 7mm distal to its origin from the rat sciatic nerve;the proximal CPN stump was then
sutured into the thigh muscles,whereas the distal CPN stump was sutured terminolaterally to the ipsilateral TN.Subsequently,a total volume of 50?l of the corresponding solution of growth factor(s) was administered in each case to the TN subepineurially,proximal to the CPN/TN coaptation site.The same surgical procedure was carried out in group C,but an equal volume of normal saline was administered instead.Finally,in each of the animals of group G,both the proximal and distal CPN stumps were sutured into the neighbouring muscles.All surgical procedures took place with the animals under dissociative anaesthesia and
were performed under sterile conditions,using the operating microscope and applying microsurgical techniques.In each case,the intact left CPN served as
intraanimal control.
Results:
The evaluation of the outcome four(4) months postoperatively was based on clinical examination, walking-track analysis,in situ electromyographic studies,Tib.
cranialis “wet muscle mass” measurement and histomorphometric studies.According to the latter,bFGF alone and NGF alone were better than placebo.BFGF
was also superior to NGF with respect to muscle histomorphometry.Finally,bFGF,NGF and their combination were better than placebo regarding the EMGparameters.All of the aforementioned differences were statistically significant (p<0.05).
Conclusions:
In rats,CPN repair via end-to-side neurorraphy to the TN can be enhanced by the subepineurial administration of bFGF and/or NGF,with an apparent advantage of the former.
Immunologic Demyelination as a Novel Therapy Following Acute Injury in the
Peripheral Nervous System: A Summary of Our Experience
Institution where the work was prepared: UC Irvine Medical Center, Orange, CA, USA
Aaron M. Kosins, MD, MBA; Thomas Scholz; Gregory RD Evans; Hans S Keirstead; University of California, Irvine
Introduction:
To improve the regenerative potential of PNS axons in vivo, we utilize a novel model to measure the regenerative potential of the peripheral nervous system
after acute injury. We demonstrate that axon regeneration within a region of acute contusion and transection injury can be measured accurately and increased
in the presence of immunological demyelination.
Methods:
Adult female Sprague-Dawley sciatic nerves were initially exposed and the results of immunologic demyelination examined in a 1cm section of nerve that contained the area of demyelination. Adult female Sprague-Dawley sciatic nerves were then contused and injected with the demyelinating agent. The sciatic nerves
were harvested 14 and 28 days following the onset of demyelination. The lesion containing length of nerve was cut into 1mm transverse blocks and processed
to preserve the cranio-caudal orientation. In another group, the sciatic nerves were exposed, transected, repaired, and injected with the demyelinating agent.
These animals were similarly euthanized at 1 and 2 months and processed to examine the extent of axon regeneration. Specimens were fixed and evaluated
using structural and immunohistochemical analysis. A Mini-Ruby Tracer was included to determine the source and direction of axonal re-growth.
Results:
A single epineural injection of complement proteins plus antibodies to galactocerebroside (the major myelin sphingolipid) resulted in maximal demyelination
followed by Schwann cell remyelination at 7 and 14d, respectively. Immunologic demyelination enhanced nerve regeneration after acute injury as measured
by total number of axons, axon density and G-ratio. Tracers further demonstrate that nerve regeneration arose from proximal motor axons.
Conclusion:
These studies demonstrate a new method to measure nerve regeneration after immunologic demyelination as well as a new therapy to enhance nerve regeneration in the PNS . Our findings indicate that peripheral nerve regeneration within a region of contusion or transection injury in the adult rat sciatic nerve can
be enhanced using a demyelinating agent. This data will be applied in the creation of tissue-engineered constructs, cell-based therapy systems, and even nerve
transfers to improve the outcome of critical nerve injuries in the PNS.
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Intravenous Copolymer Surfactant P188 Accelerates Post-Axonotemetic Neuronal Regeneration
Institution where the work was prepared: The Univesity of Chicago, Chicago, IL, USA
Neil D. Dalal, MD; Zhen-du Zhang, MD; Raphael C. Lee, MD, ScD; University of Chicago
Introduction:
Fundamentally, what determines recovery following an axonotemetic peripheral neuron injury are both the factional regeneration of axons and kinetics of reinnervation. Proximal nerve lesions in adults often result in very limited recovery. A practical method to restore neuronal continuity, prevent Wallerian Degeneration and
speed recovery would have significant value. It is well established that biocompatible copolymer surfactants like Poloxamer 188 (P188) restore structural integrity of disrupted cell membranes when applied in sub-critical micelle concentrations. The purpose of this study was to determine if P188 could accelerate recovery of
disrupted using an established axonotemetic model.
Methods:
A muscle-splitting gluteal incision was used to expose the sciatic nerve in an anesthetized 300 gram S-D rat. Baseline compound nerve action potential (CNAP)
amplitude values were obtained using a Dantec Counterpoint II for AP stimulation and recording. Then, a 10 second, No 5 jeweler’s focepts crush injury in the
center of a two centimeter segment was performed. One hour after injury, either 17 mg 10 kDa neutral dextran (osmotic control) or 17 mg 8.8kDa P188
was administered in an i.v. bolus to achieve 1mg/ml peak blood level. Sham controls consisted of surgery without crush or therapy. Recovery at a point 1 cm
distal to the injury was monitored by neurofilament histochemical staining optical density of the nerve cross-section and by the compound nerve action potential (CNAP) amplitude stimulated 1 cm proximal to the lesion. Five animals from each group were analyzed before crush and on post-crush day(PCD) 4, 14,
or 21. Post-injury CNAP normalized to pre-crush baseline. Data were analyzed by ANOVA.
Results:
The mean CNAP amplitude (millivolts) for the P188 group was: PCD#4: P188 (59±9%); PCD#14: (85 ±7.9%); and PCD#21 (97±4.7%), while the dextran controls were
PCD#4: (27±5%); PCD#14: (55±9.7%); and PCD#21(98±3.2%). CNAP differences were significant (p ≤0.01) on PCD#4 and PCD#14. Neurofilament density in distal segment axons treated with P188 nearly double dextran treated controls on PCD#4 (74±4.9% vs 46 ±0.9%) and significant ( p ≤0.01). On later dates the optical
densities were not significantly different. Essentially, P188 nearly double recovery rate (p ≤0.05).
Conclusions:
Intravenous P188 administered 1 hour after crush injury to rat sciatic nerve resulted in a far more rapid and sustained nerve recovery after axonotemetic sciatic nerve injury. These results support previous studies of surfactant therapy for CNS neurotrauma.. Further studies are underway to determine dose-response
and consequences of treatment delay on therapeutic efficacy.
Management of Complicated Brachial Plexus Tumors
Institution where the work was prepared: Washington University in Saint Louis, St. Louis, MO, USA
Jonathan Cheng, MD1; Chad A. Perlyn, MD, PhD2; Susan E. Mackinnon, MD2; (1)University of Texas Southwestern Medical Center, (2)Washington
University in Saint Louis
Introduction:
Tumors of the brachial plexus can have a direct and focused impact on the neurovascular function of the upper extremity. There is limited physiologic tolerance for
space-occupying lesions due to anatomical confinement and close proximity to adjacent nerves and vessels, and surgical management is frequently necessary. We
have recently reviewed the senior author’s experience with surgical management of brachial plexus tumors.
Between 1991 and 2007, 47 tumors of the brachial plexus were treated in 46 patients. Retrospective chart review was performed, and data were compiled
for patient demographics, presenting symptoms, preoperative imaging, tumor characteristics, and reconstructive modalities.
Results:
Analysis indicates a mean age of 43y (range 20-76), with a predilection of women over men (27 vs. 19). Interval from time of earliest symptoms to presentation to our care averaged 19.2 months (SD, ±18.2 months). Earliest symptoms were mass (43%), pain (36%), and sensory disturbance (13%) and weakness
(8%) in the hand. At the time of presentation, patients were experiencing additional and more advanced symptomatology: Pain was present in 72%, mass in
51%, sensory disturbance in 36%, and weakness in 18%. MRI was performed in all patients with accurate diagnosis of tumor size, location, and involvement
of adjacent structures, but misdiagnosis of tumor etiology in 34% of cases. Tumors were evenly distributed throughout the levels of the brachial plexus, with 79%
benign and 21% malignant, and 59% nerve and 41% non-nerve origin. Posthoc analysis with Tukey’s test revealed significant difference between sizes of benign
nerve (mean±SD, 4.2±2.8cm) and benign nonnerve (10.1±5.7cm) tumors. There was no difference in pain scores between groups. Corrections were performed for normal distribution and variance. Operative approach and reconstructive modalities will be discussed.
Conclusions:
Management of brachial plexus tumors can be difficult due to challenges of complex anatomy, preoperative diagnosis, functional preservation, and immediate reconstruction. Pain is generally not a reliable indicator of malignancy. In the presence of sensory or motor disturbance, surgical excision is recommended. Expertise in upper extremity nerve transfers and tendon transfers allows the surgeon to offer advanced options for immediate and delayed reconstruction.
Successful Surgical Approach for Treatment of Post-Traumatic Trigeminal Nerve Pain
Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA
Gedge D. Rosson, MD; Eduardo D. Rodriguez, MD; A. Lee Dellon, MD; Johns Hopkins University School of Medicine
Background:
Craniomaxillofacial surgeons must be prepared to diagnose and treat acute and chronic facial pain. Fortunately for both the patient and the surgeon, postoperative pain following extensive craniofacial surgery, for congenital, trauma, or tumor extirpation, is often modest in degree, and readily treated by traditional pain medication approaches. By definition, if pain persists for six months, then the problem of chronic facial pain arises. This pain must be distinguished
from non-traumatic atypical facial pain and traditional “tic-doloreaux.”
We sought to review our recent experience with the surgical management of entrapment or neuroma of trigeminal nerve branches for patients who failed extensive non-operative management. Patients were selected for surgery based on history of trauma to regional nerve sites, physical exam, CT scan review, computer-aided neurosensory testing, and diagnostic nerve blocks.
Methods:
We performed a retrospective review of 8 consecutive patients operated for chronic pain of trigeminal nerve branches. Inciting events included facial and orbital
fractures, facial rhytidectomy, paramedian forehead flap, and dental extractions. Our surgical procedures included hardware removal, neurolysis (decompression) and/or neuroma resection, with nerve grafting if needed. Specific nerves included supra-orbital, supra-trochlear, zygomaticofrontal, zygomaticofacial,
infraorbital, posterior superior alveolar, and inferior alveolar. 7 of the 8 patients were women (mean age 41 years, range 18 – 65).
Results:
Primary outcome measurement was patient reported pain scale score (11-point Likert scale, with a range from 0 – 10). Secondary outcome measurements
included facial sensation, neuropathic pain medication usage, and return to work. Any patient with improveme
114
ASPN Poster Presentations
The Prevention of Neuroma Formation by Electrocautery : A Experimental Study
in the Rat Common Peroneal Nerve
Institution where the work was prepared: Singapore General Hospital, Singapore, Singapore
Shian Chao Tay, MD, MS; Lam Chuan Teoh; Fok Chuan Yong; Soo Heong Tan; Singapore General Hospital
Introduction:
There have been anecdotal reports of the efficacy of electrocautery in the prevention of neuroma formation. However, this has not been investigated in the laboratory. In this experiment involving forty rats, electrocautery was applied to the terminal proximal ends of transected rat common peroneal nerves (CPN) to
evaluate its effect on neuroma formation.
Methods:
Monopolar and bipolar electrocautery set at 45W, applied for different durations (4 seconds and 10 seconds) were evaluated with the contralateral nerve serving as control. The rate of neuroma formation and the diameter of the nerve ends were evaluated histologically at three months. The dorsal root ganglions
(DRG) of 2 rats in each group was also harvested for study.
Results:
In the group which received high duration monopolar diathermy (10 seconds application), the rate of neuroma formation was 30% versus 90% in the control
group (p < 0.05). The mean diameter of the nerve ends was also smaller at 0.51mm versus 0.85mm (p < 0.05). In the group which received low duration
monopolar electrocautery (4 seconds), the rate of neuroma formation was 30% versus 83% in the control (p < 0.05). The diameter was 0.43mm versus 0.85mm
(p < 0.05). High duration bipolar electrocautery applied for 10 seconds, showed a neuroma formation of 25% versus 100% in the control group (p < 0.05).
The diameter of the nerve ends was 0.48mm versus 0.79mm in the control group (p < 0.05). The low duration bipolar group, which received bipolar electrocautery application for 4 seconds, the rate of neuroma formation was 60% versus 90% in the control group (p = 0.25). The diameter of the nerve ends was
0.52mm versus 0.76mm. The rate of neuroma formation and the difference in diameter in the low duration bipolar group was statistically not significant. Two
distinct cell types were noted in the DRGs – Type D and Type L cells (Fig 1). The proportion of Type L cells was significantly larger in the DRGs of the treatment
CPN versus the control CPN (71% vs 2.6%, p < 0.00005).
Conclusion:
This study demonstrates the effectiveness of monopolar electrocautery in reducing the rate of neuroma formation. For bipolar electrocautery, application of 10
seconds was effective in reducing neuroma formation but an application of 4 seconds was not associated with a significant reduction in neuroma formation.
Cardiac Perfusion Versus Immersion Fixation for Assessment of Nerve Regeneration
Rahul Kasukurthi, BA, Biology1; Amy M. Moore1; Arash Moradzadeh1; Michael J. Brenner, MD2; Ryan Luginbuhl1; Daniel A Hunter1; Susan E
Mackinnon1; (1)Washington University School of Medicine, (2)Southern Illinois University
Introduction:
Cardiac perfusion, which achieves systemic delivery of fixative in the living animal, is the accepted gold standard for tissue fixation. However, this method has
several disadvantages including being time consuming, requiring increased use of fixative, having technically cumbersome methodology, and necessitating animal sacrifice at time of tissue harvest. Immersion fixation, in contrast, is easily performed, requires less fixative, and minimizes operative time. Immersion fixation has been criticized for its potential to introduce unwanted artifacts into certain tissues such as brain, whose hydrophobic characteristics make fixation difficult. We investigated the validity of immersion fixation versus cardiac perfusion for assessment of peripheral nerve regeneration based on assessment of histological, histomorphometric, and ultrastructural parameters. Advances in computer-based analysis of nerve histomorphometry have improved precision and
accuracy in evaluating nerve tissue. Therefore, differences arising from fixation should be readily detectable. We hypothesized that immersion fixation would
be an equivalent alternative to cardiac perfusion tissue fixation.
Study Design:
Randomized, controlled in vivo laboratory animal study
Methods:
Eighteen male Lewis rats were randomized into 3 groups (n=6 per group) corresponding to sciatic nerve fixation by gluteraldehyde immersion; gluteraldehyde
cardiac perfusion; and paraformaldehyde cardiac perfusion. Animals initially underwent sciatic nerve transection and repair followed by tissue harvest, fixation and analysis at 3 weeks. Qualitative assessment of neural architecture was followed by binary image analysis for multicomponent analysis of peripheral
nerve histomorphometry. Stereology via a 2D Nucleator probe was applied to electron microscopy for quantitative ultrastructural analysis
Results:
Histomorphometry results from nerves fixed by immersion were similar to nerves fixed by either technique for cardiac perfusion. Qualitative assessment showed
similar nerve histology in terms of nerve architecture, vascularity, and restoration of perineurium.
Conclusion:
No qualitative or quantitative artifact was associated with immersion fixation when compared to gluteraldehyde or paraformaldehyde cardiac perfusion fixation. Immersion fixation of peripheral nerve specimens is a valid alternative to cardiac perfusion fixation for the assessment of nerve regeneration in a small
animal model.
115
A Novel in Vitro Model of Chronic Nerve Compression Injury
Institution where the work was prepared: University of California Irvine, Irvine, CA, USA
Laura Rummler, MS1; Winnie Palispis, BS2; Ranjan Gupta2; (1)Univ. of California, Irvine, (2)University of California, Irvine
Introduction:
During normal activities, peripheral nerves are often subjected to mechanical force. In some cases excessive or prolonged force may result in chronic nerve
compression (CNC) injuries. CNC injuries are the result of both ischemic and mechanical stimuli. Previous studies and our preliminary data showed that
mechanical stimuli can have a direct effect on the nerve.1-3 During the early phases of injury, Schwann cells undergo a dramatic process of demyelination,
remyelination, proliferation and apoptosis that appear to be the direct result of mechanical stimulation on the nerve.1,3 In addition, Schwann cell proliferation,
gene and protein expression are altered by applied mechanical stimulus.4 In this study, we developed an in vitro system to define the role that mechanical stimuli play in the pathogenesis of CNC injuries.
Methods:
The in vitro system is designed to apply a defined magnitude of hydrostatic compression to neural co-cultures while isolating the cells from ischemic affects.
Applying pressure to a liquid-vapor interface increases the amount of vapor dissolved in the medium, causing hyper-oxygenation and altering the pH. As such,
a feedback control system is used to regulate dissolved 02 and pH during pressurization. Purified Schwann cells were added to dorsal root ganglion (DRGs)
neuron cultures and the media supplemented with vitamin C to initiate myelination. Static compression was applied to the cells for 1-7 days. Cytotoxicity was
assessed by measuring lactate dehydrogenase (LDH) production immediately and 24 hours-post compression.
Results:
Cytotoxicity assay results showed that there was no significant production of LDH by the cultures with low levels of pressure (0.7221-0.886 PSI) for 24 hours.
A pressure of 1.19 PSI was required to elicit a response from the cells. However, when a very low level of pressure (0.348 PSI) was applied for 7 consecutive
days, the LDH levels increased. This data appears to indicate that chronic compression injury has a different affect on the nerve cells than acute compression
injury.
Discussion:
Several factors contribute to CNC injury, including mechanical stimulus, ischemia, and the immune response. Using an in vitro model enables us to isolate the
affects of mechanical stimulus on myelinated peripheral nerve cultures. Future studies will focus on defining the role that mechanical stimulation plays in the
demyelination associated with CNC injury.
References:
1. Gupta, Steward. J Comp Neurol, 2003.
2. Salzer, Wood. J Cell Biol, 1980.
3. Gupta, et al. Exp Neurol, 2006.
4. Gupta, et al. J Orthop Res, 2005.
The Use of the Ulnar Artery Perforator Fascial Flap for the Treatment of
Recalcitrant Carpal Tunnel Syndrome
Institution where the work was prepared: SIU SOM div of Plastic Surgery, Springfield , IL, USA
Damon Cooney, MD, PhD; Southern Illinois University; Mw Neumeister; SIU School of Medicine; Robert C. Russell, MD, FACS; Heartland Plastic Surgery
Background:
Carpal tunnel release is the most common peripheral nerve surgery performed in North America. Although the overall recurrence rate is very low, the volume of these
procedures performed means that recurrent carpal tunnel syndrome is a significant problem in hand surgery. Initial treatment of recurrent carpal tunnel syndrome should
address the possibility of incomplete release or iatrogenic injury but in the absence of these causes or in the presence of dense scaring or traction neuritis a tissue interposition procedure is indicated. Many alternatives have been proposed from local fat flaps to free omental flaps. We present our experience with the treatment of recurrent carpal tunnel syndrome with a ulnar artery perforator fascial flap.
Methods:
A retrospective review of the use of the ulnar artery perforator flap in 6 wrists was performed. All surgeries were performed by the senior author. The pts all
had undergone previous carpal tunnel release with an average of 1.8 prior procedures per wrist and all had EMG evidence of recurrent med nerve pathology. Carpal tunnel release was combined with interposition of a 2.5X6CM adipo-fascial flap based distally on the ulnar artery perforators.
Results:
All pts treated in this manner had improvement in their symptoms with all but one of the pts rating their outcome as highly satisfactory. Two pts with bilateral disease
elected to undergo the same procedure on the contra-lateral wrist. Donor site appearance was rated as unacceptable by one pt.
Conclusions:
We present our experience with the ulnar perforator adipo-facial flap for recurrent carpal tunnel syndrome. This procedure has had excellent outcomes but one
pt was unhappy with the donor site appearance. We compare the postoperative EMG and peripheral nerve assessments of these pts and those treated with
hypothenar fat flap interposition. In summary, this flap is an excellent treatment option for these pts but the donor site may be a concern.
CGRP Regulation of GDNF in Rat Myotubes
Institution where the work was prepared: McMaster University, Hamilton, ON, Canada
Margaret Fahnestock, PhD; Jieun Cha; James R. Bain; McMaster University
Glial cell line-derived neurotrophic factor (GDNF), which is synthesized in muscle, is a potent neurotrophic factor for motor and sensory neurons. It is responsible for survival, differentiation and maintenance of the innervating nerves. GDNF levels in muscle increase dramatically following denervation, thereby facilitating reinnervation of muscle by the motor nerves. In previous studies in our lab, we found that both motor and sensory nerves were able to protect rat skeletal muscle from denervation atrophy (Bain et al., 2001), and both motor and sensory nerves reduced the elevated levels of GDNF in muscle following denervation (Zhao et al., 2004). The mechanism by which the nerve regulates GDNF expression in muscle is poorly understood. In this study, we investigated whether
the exogenous application of homogenized rat sciatic nerve supernatant, a motor nerve neurotransmitter acetylcholine (ACh) or a sensory neurotransmitter calcitonin gene-related peptide (CGRP) could regulate GDNF levels in differentiated rat L6 myotube cell culture, a model for denervated muscle. After 6 days of
differentiation of myoblasts into myotubes, and a 48-hour treatment period, the levels of GDNF in the cell supernatant and cell lysate were analyzed using a
GDNF ELISA. The results showed that there was a significant increase in GDNF in the conditioned medium of samples treated with the homogenized nerve
supernatant and with CGRP, whereas ACh did not regulate GDNF levels. There was no significant difference in GDNF levels between control and treated samples in cell lysates under any of the treatment conditions. Since both GDNF and CGRP are significantly up-regulated following peripheral nerve injury, our
results suggest that the exogenous application of CGRP and homogenized rat sciatic nerve supernatant mimic nerve injury, thereby resulting in increased GDNF
in the conditioned medium of rat myotubes. Although GDNF is known to regulate neuronal CGRP levels, this is the first report, to our knowledge, that CGRP
can regulate muscle-derived GDNF.
116
A Double-Halved Stitch-Less Guide Allows the In-Vivo Regeneration of Rat Sciatic Nerve
Institution where the work was prepared: The Catholic University School of Medicine, Rome, Italy
Antonio Merolli, MD; Lorenzo Rocchi; Francesco Catalano; The Catholic University
Purpose:
To test in-vivo an artificial device (“NeuroBox”, patent WO/2008/029373) which, due to its structure, is able to provide mechanical protection and guidance
for axonal regeneration and does not require the use of any stitch to be sutured to the nerve stump. The device enables the safe intraoperative use of cyanoacrylic glue instead. It is widely accepted that putting the two nerve stumps under tensional stress will favour fibroblastic and myofibroblastic proliferation and
will impair axonal regeneration. But even without tensioning the stumps, it is the use of stitches for the suture (both degradable and not degradable) that promotes fibroblastic and myofibroblastic proliferation, bringing the same complications as above.
Methodology:
The key element of the NeuroBox is the flat Regeneration Chamber: in this compartment the bunch of fibers of the proximal stump is invited to spread on a
wider flat surface. A rigid poly-methylmetacrylate guide as the first prototype. Commercially available 2-ethyl-cyanacrilate was the glue of choice. The dedicated glue-compartment of the NeuroBox promotes the polymerization of the glue. Male Wistar rats weighing about 300 g were used as animal model. The
sciatic nerve was cut proximally to its bifurcation and a gap of 4 mm in length ensued. Fixation, Embedding, and Staining were followed by analysis both in
visible light microscopy and transmission electron microscopy
Results:
The normal structure of the nerve is preserved and seems not to be affected by the presence of the acrylic glue all around the fibroelastic sheath. In the
Regenerate zone large and small myelinated fibers can be seen in number matching the healthy proximal stump and intraneural vascularisation was observed.
There were no signs of intraneural fibrosis or other adverse intraneural reactions but it was notable that there was the complete absence of any fibroelastic
outer sheath.
Conclusions:
The use of stitches may be avoided since the stumps will be held in place by a glue cast around the nerve. It may be speculated, on the basis of these early
findings, that the flat regeneration chamber can promote vascularisation of the regenerated tissue avoiding the central tubular necrosis sometimes observed
with tubular guides of large diameter.
A Retrospective Analysis of the Efficacy of Collagen Tube Conduits in Peripheral Nerve Repair
Institution where the work was prepared: Regions Hospital, St Paul, MN, USA
Kirk J. Wangensteen, PhD; University of Minnesota; Loree K. Kalliainen, MD; Regions Hospital
Damage to peripheral nerves can lead to significant morbidity in manipulating and sensing the environment. With complete avulsion of a nerve, known as neurotmesis, there is no spontaneous return of nerve function. Thus, surgical repair is used to approximate nerve ends and restore motor and sensory function. Nerves
are repaired by direct end-to-end coaptation or through conduits such as nerve grafts or synthetic tubes. Recent studies suggest that polyglycolic acid tube conduits
are at least as effective as nerve grafting for repairing avulsed nerves, without the morbidity associated with graft harvesting. Nerve conduits made of collagen are
also available and have been shown to be effective in animal models of nerve repair. Collagen is an attractive material because it is porous, biocompatible,
absorbable, and it is widely used as a sheet graft to cover wounds. To date, however, there is no comprehensive study on the efficacy of collagen implants to repair
nerve defects in humans.
We present our experience with nerve repair using an FDA-approved nerve conduit made of type 1 collagen called NeuroGen. Our hospital is a regional level
I trauma center that routinely performs reconstructive procedures including nerve repair. We performed a retrospective study of the safety and efficacy of
NeuroGen conduits in more than 100 patients over five years. We used pre-operative, operative, and follow-up notes to record patient age, nerve(s) repaired,
time to repair, gap-width spanned, complications, and subjective and objective restoration of nerve function. Qualitative and quantitative analyses of safety
and efficacy are being conducted using our data set. We plan to present the success rate for our procedures so that patients and surgeons can make informed
decisions about nerve reconstructive surgery.
The Demographics of Cubital Tunnel Syndrome
Institution where the work was prepared: University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Sanjay Naran, BS1; Joseph Imbriglia, MD2; Ronit Wollstein, MD2; (1)University of Pittsburgh School of Medicine, (2)University of Pittsburgh Medical Center
Background:
Cubital tunnel syndrome (CUTS) is currently regarded as one entity; we hypothesize that CUTS is not a homogeneous entity, and that patients can be divided
by age into distinct groups. We predict that older patients are more likely to be male and present with an insidious onset of sign and symptoms, while younger
patients are more likely to be female and present with more acute symptoms of ulnar nerve irritation and less objective signs of intrinsic weakness and atrophy.
Methods:
A retrospective review of patients with CUTS treated surgically in the last 10 years at our institution was performed. Patients with traumatic nerve injury, systemic diseases affecting peripheral nerves and patients with insufficient information were excluded. Demographic information and characteristics of presentation were recorded, and logistic regression analysis used to evaluate the relationship between age and the parameters of CUTS on presentation.
Results:
Seventy-four patients were eligible; 51 (71%) male and 23 (29%) female. Average age at presentation was 56 years. Fifty-nine percent affected the dominant
hand. Fifty-five percent of patients endorsed heavy lifting or weight-lifting. Logistic regression analysis found a statistically significant inverse relationship between
age at presentation and interosseous muscle weakness (p=0.01) and the existence of muscle atrophy (p=0.015). There was no statistically significant relationship between age and the appearance of ulnar sensory symptoms (p=0.988), a positive Tinel test at the cubital tunnel (p=0.075), or the incidence of transposition at the time of surgery (p=0.7).
Conclusions:
CUTS is currently regarded as one entity; we believe that this may be the reason for differing results with different conservative and surgical techniques. Our
results support the hypothesis that the presentation of CUTS in older patients is more insidious and predominantly motor. This emerging concept may change
the treatment approach for CUTS, since different pathologies may require different forms of treatment.
117
“Painful Surgery” – A Dramatic Technique to Treat Localized Refractory Pain
Millicent Odunze, MD, MPH1; N. Ake Nystrom, MD, PhD2; Gregory A. Dumanian, MD1; (1)Northwestern University Feinberg School of Medicine,
(2)University of Nebraska Medical Center
Background:
The treatment of chronic pain is challenging. When standard therapies fail, there remains little to offer the debilitated patient. “Painful Surgery” is a technique
whereby awake, sedated patients guide the surgeon to the painful site in real time during the procedure. Minimal amounts of local anesthetic are used in the
skin and subcutaneous tissues to keep the procedure tolerable, but not enough is used to anesthetize the painful site. “Painful Surgery” is reserved for pain that
is of an unusual origin, is located at an unusual site, has been missed on prior exploration, and/or fails to respond to standard treatment. The technique is akin
to awake craniotomy in which oral feedback from the patient allows maximal tumor excision while protecting critical brain functions.
Objective:
Our goal is to describe a surgical technique that has been used successfully to treat localized, reproducible chronic pain that is unusual in nature or that has
been refractory to other treatment modalities and to analyze our results.
Methods:
Six patients with chronic localized pain underwent “Painful Surgery” for the excision of painful loci. Sites of painful loci included the ankle, groin, transradial
amputation stump, lower abdomen, and paramedian lower back. Five sites were post-surgical and one site was post-laser vein ablation. Once the locus was
identified intraoperatively with the patient’s guidance, additional local anesthetic was injected at the site in order to allow definitive resection. After resection,
further digital palpation demonstrated no residual painful areas. The long-term outcome of surgery was determined by telephone questionnaire. The patient’s
preoperative pain score was compared to the postoperative score. Pain scores were determined using a numerical rating scale from 0 (no pain) to 10 (the
worst pain imaginable). A positive outcome was defined as a reduction in the preoperative pain score.
Results:
The mean duration of pain before “Painful Surgery” was 15.9 months (range, 7 to 36 months). The mean follow-up was 14 months. Five patients demonstrated a positive outcome. Of these patients, the mean preoperative pain score was 8.0 and the mean postoperative pain score was 0. The patient who underwent laser vein ablation demonstrated no change in the preoperative pain score.
Conclusions:
“Painful Surgery” is a reliable intervention for the removal of painful loci when standard treatment modalities have failed. Oral feedback from the awake patient
is vital to the success of this treatment modality.
Multi-prong Management of Chronic Neuropathic Pain
Institution where the work was prepared: Hand and Microsurgery Center of El Paso and UTEP, El Paso, TX, USA
Jose J. Monsivais, MD; Hand and Microsurgery Center of El Paso; Kris Robinson, PhD, FNP; University of Texas at El Paso; Diane B. Monsivais, PhD, RN;
The University of Texas at El Paso
Introduction:
Pain is the most common reason that individuals seek healthcare. Yet, seventy-five percent of chronic pain sufferers are undertreated; still others are misdiagnosed. This results in a great drain on the economy and the health care system. Chronic pain affects 76.5 million people with an annual cost of $100 billion
in health care, lost work productivity, and reduced income. A frequent reason for under treatment is the inadequate assessment of pain. The second most common is a misunderstanding of the use of multiple drug combinations and the proper use of opiods and management of co-morbidities, such as anxiety, depression, sleep disorders, deconditioning and endocrinopathies.
Purpose:
The purpose of this presentation is to expose the hand and peripheral nerve surgeon to current clinical practice guides for chronic neuropathic pain management. The treatment of neuropathic pain management goes beyond regional assessment and localized treatment to include central and peripheral nervous and
endocrine systems, as well as the psychosocial aspects of the whole person. Therefore, a multi-prong approach to neuropathic pain management in a specialty
clinic is essential to improved function, patient satisfaction, and overall quality of life.
Methods:
An exploratory, correlational research design guided this study. Through convenience sampling, we recruited 92 patients seeking pain management treatment
for a neuropathic condition at a hand and microsurgery specialty clinic. Treatment consisted of a) psychosocial support (acknowledgement and listening); b)
pharmacological agents for pain including opiods with a pain contract; c) supportive therapy, i. e. physical therapy or peripheral nerve blocks; d) physical conditioning; and e) management of co-morbidities, such as thyroid or androgen replacement for endocrinopathies, SSRIs or SNRIs for depression, membrane
stabilizers for neuralgia, and hypnotics for sleep disorders. In addition, we contracted a date to return to work with worker’s compensation patients. A statistician calculated descriptive statistics and conducted Pearson correlation coefficients and post hoc analyses (linear regression, ANOVA and MANOVA). We
compared SF36vr2 scores of first time patients against scores of previously treated patients for function and quality of life.
Results:
A multi-modality treatment plan led to enhanced function and quality of life in this group of patients. We will present case studies to illustrate how a multidimensional assessment combined with multi-prong treatment approach influences function and quality of life.
Peripheral Nerve Repair with Vein Sleeve
Institution where the work was prepared: University of Alabama at Birmingham, Birmingham, AL, USA
James A. Chambers, MD, MPH; James N. Long, MD; University of Alabama at Birmingham
One of the most critical components in achieving good outcomes in peripheral nerve repair is tension-free apposition. A very common complication of peripheral nerve repair is neuroma. Both tension-free apposition and neuroma prevention can be facilitated by peripheral neurorrhaphy using a vein sleeve (not conduit) which functions to remove tension while enveloping the site. Crude attempts at this technique have been described in war wounds over 50 years ago, and
modern microsurgical techniques have demonstrated the efficacy and advantages of this approach in laboratory dogs.1 We report the application of the autologous vein sleeve for nerve repair in median nerve repair with good clinical results and that encourage further investigation into the use of this technique.
1. Calteux, N, et al., “Utilisation d’un segment veineux
dans la réparation des nerfs peripheriques,” Ann Chir
Main, 1984;3(2):149-55.
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[The Controlled Release of GDNF from a Fibrin Based Delivery System
Enhances Motor Nerve Regeneration
Amy M. Moore, MD1; Matthew D. Wood1; Wilson Z. Ray1; Christina M. Magill1; Nancy L. Solowski1; Elizabeth L. Whitlock1; Daniel A. Hunter1; Susan E.
Mackinnon1; Shelly Sakiyama-Elbert2; Gregory H. Borschel1; (1)Washington University School of Medicine, (2)Washington University
Purpose:
Despite recent advances in the understanding of nerve injury and regeneration, functional outcomes remain suboptimal. Supplementation with a motor specific neurotrophic factor may improve motor nerve regeneration, and ultimately function, by enhancing regeneration of motor axons. To this end, we investigate
the use of a nerve guidance conduit (NGC), a known alternative to autograft repairs, filled with a novel fibrin based delivery system that allows regenerating
fibers to have cell mediated exposure to neurotrophic factors.
Methods:
The rat femoral motor nerve model was employed to examine the direct effects of the controlled delivery of a motor specific neurotrophic factor (Glial Cell Linederived Neurotrophic Factor, GDNF) in comparison to a sensory specific factor (Nerve Growth Factor, NGF) on motor nerve regeneration across a 5mm nerve
gap. Seven experimental groups (n = 8) were evaluated consisting of GDNF or NGF with the delivery system(DS) within the conduit, control groups excluding
one or more components of the DS, and nerve isografts. Nerves were harvested 5 weeks after treatment for analysis by histology, histomorphometry, electron
microscopy, and retrograde labeling.
Results:
Preliminary results from all groups (n=3) reveal that the total number of nerve fibers at 5mm distal to the conduit was statistically greater with the GDNF and
NGF with DS groups in comparison to the negative controls. The isograft had a significantly higher fiber number; however, there was no statistically significant
difference when examining fiber density and percent neural tissue, both measures of nerve quality, between the isograft and growth factor and DS groups.
Interestingly, the GDNF with DS group exhibited significantly larger fiber width distribution than all groups and had more organized nerve architecture on histology and electron microscopy, suggesting more mature nerve fibers. Retrograde labeling results are pending.
Conclusion:
The controlled delivery of GDNF and NGF enhance nerve regeneration in the femoral motor nerve model. Although not exceeding regeneration of the isograft, the GDNF with the delivery system group demonstrated larger diameter nerve fiber size and more organized nerve architecture in comparison to the
sensory specific NGF group and controls. This study gives insight into the potential beneficial role of GDNF in the treatment of motor specific nerve injuries.
Selective Marginal Mandibular Neurectomy to Augment Smile Symmetry in Hemifacial Microsomia
Jonathan Ferrari; Union Memorial Hospital; Jie Xu, MD; Hahnemann University Hospital; Ramon DeJesus, MD; Upper Chesapeake Medical Center
Deanimation techniques, such as botulinum toxin injections may temporarily resolve lip deformities and restore a symmetrical smile, but many patients seek more permanent results. Selective marginal mandibular neurectomy (SMMN) is an effective permanent deanimation technique to reconstruct symmetrical smiles in conditions
associated with unilateral facial paralysis, such as hemifacial microsomia. In the past, this technique was not widely practiced due to lack of predictability and results,
as well as concerns with oral function and cosmetic consequence. In concordance with a study published in 2005 from Breslar et al, we agree that SMMN is a safe
and effective method for correcting focal unilateral facial palsies. Additionally, we suggest that SMMN should be considered in patients who have completed mandibular & soft tissue reconstruction for Hemifacial Microsomia and are still unsatisfied with the cosmetic result. This case describes SMMN performed on a 48 year old gentleman suffering from an asymmetric smile from left sided lower lip droop secondary to hemifacial microsomia.
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ASRM - Research I
Tolerance to a Composite Tissue Allografts after the Induction of Mixed
Chimerism In a Pre-Clinical Large Animal Model
David W. Mathes1; James Edwards1; Jeff Scott1; Tiffany Miwongtum1; Scott Graves, PhD2; Rainer Storb2; (1)University of Washington, (2)Fred Hutchinson
Cancer Research Center
Introduction:
The feasibility of composite tissue allografts (CTA) has been demonstrated by the successful transplantation of the hand, abdomen and face. The survival of the
transplant is dependent on chronic immunosuppression and all have experienced episodes of skin rejection. While tolerance to the skin has been achieved in
small animal models it has remained elusive in a large animal model. The purpose of our experiment was to examine if tolerance to a CTA could be achieved
after the establishment of mixed chimerism in a pre-clinical canine model.
Methods:
Four canines underwent our mixed chimerism protocol of 200 cGy of total body irradiation followed by a stem cell transplant from a MHC matched, minor
mismatched donor. A 28-day course of cyclosporine and mycophenolate mofetil was given to each canine. Donor cell chimerism was demonstrated by PCR.
Three months after stable engraftment the four canines underwent a CTA transplant (a myocutaneous rectus flap based on the deep epigastric artery and vein)
from the stem cell donor. As a control two naïve canines underwent CTA transplant across the same barrier. Donor cell chimerism was again monitored. In
addition, we followed the mRNA expression of FoxP3 in the CD3+ cells from peripheral blood and from the muscle of the CTA. The allografts were examined
through histologic analysis. Mixed lymphocyte reactions (MLR) studies were performed to demonstrate an intact immune system.
Results:
The control canines rejected their allografts in 15 and 24 days as evidenced by gross and histology. The 4 experimental animals have no evidence of rejection
in either the skin or the muscle (>200, >185, >135, and >40 days) by both gross and histologic analysis. Donor cell chimerism has been stable in the canines
(granulocyte levels ranged from 41 to 98% donor and mononuclear levels ranged from 52 to 98%). The expression of FoxP3 in the tolerant animals initially
decreased in the peripheral blood as those cells migrated into the allograft but then began to recover by the 5th week post transplant. Expression in the muscle, however, remained elevated during the entire course of the transplant. MLR demonstrated normal third party response indicating an intact immune system.
Conclusion:
This mixed chimerism protocol was successful in generating stable mixed chimeras without complication. All animals accepted vascularized composite tissue allografts
without any posttransplant immunosuppression . This is one of the only pre-clinical large animal models to demonstrate tolerance to the skin portion of the CTA.
Sacrificial Microfiber Networks: Towards the Fabrication of Vascularized Tissue Constructs
Institution where the work was prepared: Weill Cornell Medical College, New York, NY, USA
Leon M. Bellan, BS, MS1; Harold G. Craighead, PhD1; Sunil P. Singh, BA2; Jason A. Spector, MD3; (1)Cornell University, (2)New York University, (3)Weill
Cornell Medical College
Background:
Although tissue engineering approaches hold great promise towards “the development of biological substitutes that restore, maintain or improve tissue function” (Skalak
and Fox, 1988), the critical limiting step remains the ability to design constructs that have their own inherent vascular network. We have developed a technique with
which we believe to be an important first step towards the production of an engineered construct with an inherent three-dimensional vascular network.
Our fabrication technique begins with the creation of sacrificial microfiber networks (SMNs). Using a commercially available extruder, crystalline sugar is melted
and extruded into meshed fibers whose diameters are similar to those of capillaries, small arterioles and venules. Liquid polydimethylsiloxane (PDMS) is then poured
over the SMN. When the resin has crosslinked and the polymer is a solid structure, the sugar based fiber network is removed by placing the construct in warm
water for several days. Dissolution, or sacrifice, of the fiber network leaves an intact, complex three dimensional network of microchannels. Sacrificial structures with
macroscale sizes (1-2mm diameter), used to form arteries and veins, can be produced by extruding sugar cylinders using standard polymer extrusion equipment.
These larger structures are inserted into the SMN, and the whole sugar structure is “welded” at the contacts between individual sugar strands by placing it in an
incubator for a short period of time (minutes). Constructs were then analyzed by scanning electron microscopy, as well as light and dark field microscopy. Flow
through the constructs was demonstrated using fluorescent microspheres (2µm diameter) and heparinized whole rat blood with fluorescently labeled erythrocytes.
Results:
PDMS constructs were poured into rectangular shapes approximately 20x20x8mm (length/width/thickness). Sacrificial microfiber networks embedded within PDMS blocks
result in a relatively homogeneous distribution of interconnected microchannels within the construct with channel diameters ranging from 10-50µm. Macroscopically, when
injected through the “arterial” input, blood is seen to cause a blush within the construct, and exit via the “venous” output. Fluorescent microscopy demonstrates directional
flow of both microspheres and erythrocytes within the constructs’ microchannel network.
Conclusions:
Our constructs contain a complex three dimensional microchannel architecture which not only resembles that of vascularized tissue but that also demonstrates
flow within it. Importantly, this technique is readily scalable and can produce structures several centimeters thick. Although only a first step, we believe our novel
approach represents a major step forward toward the creation of vascularized tissue constructs.
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In Vivo Tissue Construct and Growth Chamber Interface: Surface Modification
to Optimize Tissue Engineered Construct Yield
Ian F. Lytle, MD; Deborah Buffington; H. David Humes, MD; David L. Brown, MD; University of Michigan
Introduction:
Vascularized tissue constructs can be developed in-vivo by placing silicone chambers around a vascular pedicle. The chamber spontaneously fills with vascularized
tissue, which can be seeded with a variety of cultured cells, generating specialized and functional constructs. Experience has shown that as constructs mature the tissues contract in a similar fashion to capsular contraction around surgically placed implants and the construct decreases in size significantly. We hypothesize that modification of the chamber’s surface at its interface with the tissue construct; adherence can be promoted within the developing chamber. This will oppose the contractile
force and thus increase tissue yield, producing larger tissue constructs.
Methods:
Three different chamber surfaces were tested. Group 1 (Smooth) consisted of smooth silicone tubing and acted as the control. Group 2 (Punched) utilized the
same tubing with multiple holes punched through the chamber, providing anchoring points for the developing construct. Group 3 (Textured) had a commercially available textured surface applied to the inner surface. The microstructure of the textured surface has been proven to support tissue ingrowth. The chambers
were placed around intact vascular pedicles of F-344 rats for 14 weeks. At explantation, the constructs were removed from the chambers, weighed and measured. Histological characteristics were evaluated.
Results:
The average tissue mass for the explanted constructs were 50, 100, and 120 mg for groups 1, 2, and 3 respectively (p < 0.01). The average calculated volumes for the constructs were 74, 158 and 176 µl (p < 0.05). The figure demonstrates the effects of capsular contraction on the Smooth chamber’s construct. In
contrast, the Punched and Textured constructs remain robust. The area of vascularized tissue was also calculated using histological images and was found to
be 1.6, 6.7 and 8.7 mm2, for groups 1, 2, and 3 respectively (p < 0.01). The paucity of vascular tissue in the Smooth group as compared to the Punched and
Textured groups is also demonstrated in the figure’s cross-sections.
Conclusions:
By modifying the interface of the chamber and construct with either punched holes or a textured surface, the generated tissue that remains within the chamber
is significantly greater than the control. By maintaining the tissue construct’s size and vasculatiy, a larger bed of vascularized tissue is available as a foundation for developing larger and increasingly complex tissue engineered constructs. Acknowledgements: This study was supported by US Army Medical Research
and Material Command (Contract Number W81XWH-05-2-0010).
A Novel Sutureless Technique for Microvascular Anastomosis Using Thermoreversible Poloxamers
Institution where the work was prepared: Stanford University, Stanford, CA, USA
Edward I. Chang, MD; Cynthia D Hamou; Michael G Galvez; Samyra El-ftesi; Jayakumar Rajadas; Michael T Longaker; Geoffrey C Gurtner; Stanford University
Introduction:
The ability to perform microvascular anastomosis for free tissue transfers and digital replants is tedious, time consuming, and requires a skilled microsurgeon.
While a myriad of devices have simplified these complex operations, all the current devices introduce foreign materials which stimulate a foreign body reaction predisposing such anastomoses to stenosis or thrombosis. We propose a novel sutureless technique using thermoreversible poloxamers.
Rheological studies were used to engineer a formulation of P407/P188 to obtain a phase transition temperature at 40°C. Poloxamer formulations were tested
on HUVECs in vitro to assess for toxicity and effects on proliferation. Anastomoses were performed on Fisher rat aortas (avg. diameter 1.18±0.02mm) using
our sutureless technique (n=30) and with conventional 10-0 nylon sutures (n=30). CT angiograms, ultrasound Doppler, burst strength assays, and histology
were performed at designated timepoints. Poloxamer mediated heparin delivery was assessed in vitro using HUVECs and tissue factor pathway inhibitor (TFPI)
ELISA.
Results:
A engineered poloxamer formulation with an elastic modulus greater than 20,000 kPa with a phase transition temperature of 40°C was used for all subsequent experiments. Sutureless anastomoses were completed more efficiently than with the hand sewn technique (8.1 ± 2.4 min vs. 47.3 ± 5.0 min, p<0.05)
with equivalent burst strengths (>1200mm Hg, p>0.05). CT angiograms demonstrated equivalent patency in end-to-end anastomoses; however, end-to-side
anastomoses could not be performed using traditional techniques (p<0.001). MR angiograms performed one year post operatively demonstrated equivalent
patency in end-to-end anastomoses (p>0.05). Doppler analysis demonstrated equivalent patency, vessel diameter, and volumetric flow (116.1mL/sec vs. 107.2
mL/sec, p>0.05) between sutureless and hand-sewn anastomoses. Histology demonstrated dramatically decreased inflammation and fibrosis in the sutureless
group compared with the traditional technique. Application of poloxamer did not demonstrate any evidence of toxicity in vitro or in vivo. Heparinized poloxamer-induced a significant percentage increase in secretion of TFPI compared with heparin administered directly to HUVECs (231.8%, p<0.05) with effects
lasting up to 24 hours (125.4%, p<0.05).
Conclusions:
Sutureless anastomosis can be performed reliably, more efficiently, and with less intimal damage than hand-sewn anastmosis. In addition, poloxamers can also
be employed as a delivery agent for anti-thrombotics simultaneously to further preserve graft patency. This technology offers a promising alternative to sutured
anastomosis and may have a profound impact on the field of reconstructive microsurgery.
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Mesenchymal Stem Cells Prolongation of Composite Tissue Allotransplantation Survival in a Swine Model
Institution where the work was prepared: Yur-Ren Kuo, Kaohsiung, Taiwan
Yur-Ren Kuo, MD, PhD, FACS; Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University; Hsiang-Shun Shih, MD; Chang Gung
Memorial Hospital; Shigeru Goto, MD, PhD; Chang Gung Memorial Hospital-Kaohsiung Medical Center; Feng-Sheng Wang; Chang Gung Memorial
Hospital at Kaohsiung; Fu-Chan Wei, MD, FACS; Chang Gung Memorial Hospital, Chang Gung University and Medical College; W.P. Andrew Lee;
University of Pittsburgh
Background:
Composite tissue allo-transplantation (CTA) is limited by the risk of long-term therapeutic immunosuppression. Evidence demonstrated mesenchymal stem cells
(MSC) could suppress T-cells proliferation in vitro and prolong allograft survival in rodent model.. This study investigated whether MSC combined with bone
marrow transplantation (BMT) and short short-term immunosuppressant could prolong allograft survival in a swine hind-limb model.
An out-bred miniature swine underwent transplant of a heterotopic hind-limb CTA model consisting of distal femur, knee joint, tibio-fibula and surrounding muscle with a vascularized skin paddle. Group I (n=5) did not receive immunosuppressive therapy as a control group. Group II (n=6) received cyclosporine (CsA
day 0~+28; 10mg/kg for 2 weeks then 5 mg/kg for 2 weeks). Group III (n=4) received irradiation (day -1; 150cGY total body irradiation (TBI) and intra-thymus 1,000 cGY), BMT (day +1), and CsA (day 0~+28). Group IV (n=5) received irradiation (day -1; 150cGY TBI and intra-thymus 1,000 cGY), BMT (day
+1), CsA (day 0~+28), and MSC (day +7, +14, +21). Swine viability and the rejection signs of allograft were monitored postoperatively. Histopathological
changes of allograft examined using H&E staining. MSC-Brdu labeling study were examined the homing of recipient after donor MSC injection.
Results:
The results revealed a progressive rejection of the CTA by day 9 to 14 in the controls. The allograft with short-term CsA treatment revealed delayed the rejection between day 28 and day 45 postoperatively. The BMT-CsA group revealed no significant prolongation of allograft survival as compared to CsA treatment
group. However, the MSC-BMT-CsA group revealed significant prolongation of allograft survival (> 200 days) as compared to other groups without MSC. The
histological examination of allograft biopsy showed less inflammatory cells infiltration in allo-skin and interstitial muscle layers in the MSC-BMT-CsA group as
compared to other groups without MSC. The MSC-Brdu labeling study revealed the donor MSC engraftment in the recipient skin and liver parenchymal tissue.
Conclusions:
This study demonstrated that combined MSC-BMT-CsA treatment could prolong CTA survival. MSC infusion provides a potential strategy to clinically improve
allograft survival and induce immune tolerance.
Novel Approach to Tissue Engineering and Gene Therapy Using Bioreactor Manipulated Explanted Microvascular Beds
Institution where the work was prepared: Stanford University School of Medicine, Stanford, CA, USA
Edward I. Chang, MD; Samyra El-ftesi; Ivan N Vial; Denise A Chan; Geoffrey C Gurtner; Stanford University
Introduction:
The ability to engineer a neo-organ using traditional tissue engineering technology is limited by the ability to provide the construct with a stable, efficient vascular network. Using the already established patterned vasculature of free flaps, we hypothesize that mesenchymal stem cells (MSCs) can be seeded onto our
explanted microvascular beds (EMBs) for tissue regeneration.
EMBs based upon the superficial inferior epigastric vascular pedicle were harvested from female Sprague Dawley rats and perfused on the bioreactor. Standard
culture media and synthetic hemoglobin (Hemopure) were used as perfusates. Male rat bone marrow derived MSCs and human adipoderived MSCs were harvested from liposuction specimens. Both populations of MSCs were fluorescently labeled with PKH26. Bone marrow MSCs were transfected with a Renilla luciferase
plasmid to determine the possibility of utilizing MSCs for replacement of deficient proteins.
Results:
Explanted microvascular beds could be sustained on the bioreactor for up to 16 hours using standard culture media. Hemopure was engineered to maintain
physiologic oxygen delivery up to 48 hours and extended EMB viability on the bioreactor to 24 hours verified through NBT staining as well as following reimplantation. Rat bone marrow derived MSCs as well as human derived adipo-MSCs successfully engrafted into the EMBs forming clusters near native vasculature.
FISH analysis for the Y-chromosome further confirmed successful engraftment of stem cells into the flap. BrdU staining demonstrated not only stem cell engraftment but also active proliferation suggesting the seeded stem cells could potentially be directed towards regeneration of a neo-organ. Finally, rat bone marrow
derived MSCs were transfected to express a Renilla luciferase, and luciferase enzyme activity was demonstrated in vitro. Transfected MSCs were then seeded onto
the EMB and reimplanted into a recipient. Following injection of the luciferin, targeted expression of luciferase activity was identified only in the EMB. This further
confirmed successful stem cell engraftment, but more importantly, the potential for this technology to deliver targeted and sustainable gene therapy.
Conclusions:
Using the existing microvasculature of free flaps (EMBs), MSCs can be seeded efficiently through the bioreactor and manipulated for tissue engineering purposes. MSCs can then be directed towards differentiation or transfected to secrete proteins for correction of inborn errors of metabolism. Using this technology, we are able to overcome the obstacles of current tissue engineering paradigms that continue to be limited by the inability to recreate an efficient microcirculatory system able to sustain the engineered construct.
122
Effects of High Dose Radiation on Hypoxia-Induced Neovascularization
Institution where the work was prepared: New York University Langone Medical Center, New York, NY, USA
Phuong D. Nguyen, MD; Oren Z. Lerman, MD; Robert J. Allen Jr, MD; Vishal Thanik; Christopher C. Chang; Stephen M. Warren; Pierre B. Saadeh; Jamie P.
Levine; New York University Langone Medical Center
Background:
Impaired vascularization and tissue damage after high dose radiation injury is an observed, yet poorly understood phenomenon, encountered routinely by
reconstructive microsurgeons. However, on a molecular level, the effect of radiation (XRT) on endothelial progenitor cell (EPC) mediated vasculogenesis is
unknown. We hypothesize that high dose radiation impairs vasculogenesis, leading to diminished ability for tissue repair and decreased vascularity at radiation injury sites.
Methods:
In-vitro: human umbilical vein endothelial cells (HUVECS) were irradiated (20 Gy) and placed either in normoxic (21%02) or hypoxic (1%02) conditions. HIF1 protein was analyzed via Western Blot (48 hours). SDF-1 mRNA was quantitated using real time RT-PCR (from 24 to 72 hours after XRT). In vivo: Dorsal skin
flaps were created on adult FVB mice and irradiated (20 Gy). Vascular perfusion was evaluated via laser doppler (days 0, 2, 7, and 14). Flaps were harvested and stained for CD31 (day 14). FVB mice underwent Tie2/LacZ bone marrow transplant, and flaps were created and evaluated for neovascularization by
beta galactosidase staining (day 14). Peripheral blood EPCs were evaluated by flow cytometry on separated Flk1+/Sca1+/Lin- mononuclear cells (day 7).
Results:
Irradiated HUVECS demonstrated decreased HIF-1 protein compared to controls. Conversely, hypoxia stimulated SDF mRNA compared to normoxic controls
(6 fold increase), initially doubling in the XRT group (p<0.05) at the earliest time points. However, at 48 hours and thereafter, XRT blunted the hypoxic stimulus
by at least half (4.3 vs. 8.5 fold SDF increase; p<0.05). Skin flap vascularity diminished by 50% at day 7 (p<0.05). CD31 expression was decreased in irradiated flaps at day 14 (172 positive cells/hpf vs. 157 cells/hpf; p<0.05). Irradiated flaps in Tie2/LacZ transplanted animals showed a 6-fold decrease in LacZ
expressing cells at day 14 compared to non-irradiated flaps. Peripheral blood EPC levels were increased 2.5 fold (0.35% vs. 0.86%; p<0.05).
Conclusions:
Though an initial increase in EPC mobilization into peripheral blood presumably due to transient increase in chemoattractant SDF-1 was observed, later effects
of irradiation show blunted hypoxia responsiveness and decreased vascularization. This may be due to impairment of EPC homing stimulus at the tissue level.
These findings increase our understanding of vasculogenesis after XRT, and identify potential therapeutic targets to ameliorate the dysfunctional homing of mobilized EPCs.
Fully MHC-Mismatched Face Transplantation: Comparison of the Tolerogenic
Effects of Different Cell–Based Supportive Therapies
Mikael Hivelin, MD; Erhan Sonmez; Aleksandra Klimczak; Serdar Nasir; James Gatherwright; Maria Siemionow; Cleveland Clinic
Background:
Composite tissue allografts linked reconstructive microsurgery with modern fields of transplantation. The lifelong immunosuppression is required, and its side effects
could be minimized by the induction of donor specific tolerance through mixed chimerism. In face allograft model we compared the tolerogenic effects of three different cell-based supportive therapies including the transplantation of donor bone marrow cells (BMC), donor bone marrow stromal cells (BMSC), or donor/recipient
chimeric cells (D/RCC), under a 7 day non-myeloablative immunosuppressive protocol.
Methods:
32 fully MHC-mismatched hemiface transplantations were performed between ACI(RT1a) donors and LEW(RT1l) recipients in 4 groups under a 7 day protocol of anti-·/‚TCRmAb and Cyclosporin A. Group 1: Control, without cell supportive therapy. Group 2: BMC therapy (100x106 cells). Group 3: BMSC therapy (5x106 cells). Group 4: D/RCC therapy (10x106 cells). 50% of allograft recipients received a cell therapy booster at day 21 post-transplant. Before
intraosseous transplantation, the bone marrow derived cells were stained with PKH-26 dye to evaluate migration and engraftment. The assessment methods
included: Clinical and histological (hematoxylin-eosin) grade of rejection and immunohistochemistry for donor cell engrafment. Donor-specific chimerism for
MHC class I (RT1a) antigens in blood and bone marrow compartments, and regulatory T-cells (CD4/CD25) blood levels were detected by flow cytometry.
Results:
The controls, without cellular therapy, rejected between 19 to 27 days post transplantation. Allografts with BMC, BMSC and D/RCC rejected between 33 to 38, 31
to 33, and 26 to 29 days respectively. Survival was significantly increased in all cell therapy groups compared to controls (p=0.0067 to p=0.0177). The BMC and
booster groups had the longest survival and BMC booster, delayed the onset of rejection up to day 48 (still under observation). The highest levels of chimerism for
T-cells (CD4/RT1a and CD8/RT1a) and B-cells (CD45RA/RT1a) were obtained with BMC, as follow: 79.7% and 1.59% at 7 days, 16.6% and 2.05% at 21 days,
25.2% and 2.83% at 35 days post-transplantation respectively. Regulatory T-cells (CD4/CD25) reached maximum levels at day 21 in all groups: BMC: 3.13%,
D/RCC: 2.7% and for BMSC: 2.66%.
Conclusion:
Cell supportive therapies, significantly delayed the rejection in fully mismatched face allografts via induction of donor chimerism and regulatory T-cells, under
a 7 days ·/‚TCRmAb/CsA protocol. BMC supportive therapy, as well as BMC booster, significantly extended allograft survival when compared to BMSC or
D/RCC therapies. The extension of survival correlated with high levels of donor B-cells (RT1a/CD45RA), chimerism in the peripheral blood of recipients.
123
Pulsed Acoustic Cellular Therapy as a Protective Technology Against Ischemia/Reperfusion
Injury in Skeletal Muscle. A Preliminary Report
Joanna Cwykiel, M, Sc; Lukasz Krokowicz; Aleksandra Klimczak; Maria Siemionow; The Cleveland Clinic
Purpose:
Ischemia/reperfusion injury (IRI) is a multi-factorial antigen-independent inflammatory process that affects negatively tissue function and graft survival after surgical
trauma. Despite practical indications of Pulsed Acoustic Cellular Therapy (PACE), its effect on reduction of inflammation and tissue regeneration is still unknown. We
hypothesized that PACE induces neoangiogenesis and improves blood supply to tissues. The aim of this study is to investigate whether the Pulsed Acoustic Cellular
Therapy stimulates anti-inflammatory and pro-angiogenic effects in ischemic muscle flaps.
Methods:
Cremaster muscles intravital microcirculation recorded: 1) Non-ischemic controls, 2) 5hrs ischemia control; 3) pre-ischemic (5hrs) PACE therapy 4) post-ischemic
(5hrs) PACE therapy.
Assessments:
Microcirculatory hemodynamics (capillary perfusion, leukocyte-endothelial interactions); immunohistochemistry (leukocyte trafficking – expression of cell adhesion molecules: E-selectin, ICAM-1 and VCAM-1; vasculogenesis: VEGF, von Willebrand factor (vWF). Taqman real-time RT PCR gene expression: pro-angiogenic factors (Vegfá, Vwf, eNos) and, pro-inflammatory factor (iNos) and pro-angiogenic chemokines (Ccl2, Cxcl5) and chemokine receptors (Ccr2 and Il8rb).
Results:
Pre-ischemic PACE therapy decreased rolling and sticking leukocytes at muscle flap microcirculation and this correlated with down-regulation of ELAM-1 and ICAM1 compared to ischemic controls. Lack of VCAM-1 protein expression was observed after pre-ischemic PACE treatment. Post-ischemic PACE increased functional capillary density, decreased activation of rolling and sticking leukocytes that correlated with down-regulation of ELAM-1 and VCAM-1 protein expression. Post-ischemic
PACE resulted in up-regulation of VEGF and vWF expression on the vessel endothelium. Pre-ischemic treatment favored expression of pro-angiogenic gene Vegf,
inflammatory gene iNos and Cxcl5, Ccl2 chemokine but had no effect on Vwf and eNos gene expression. Post-ischemic treatment significantly decreased gene expression of pro-inflammatory factor (iNos) and pro-inflammatory chemokines Ccl2 and Cxcl5. Either pre- or post ischemic PACE treatment had no effect on gene expression level of chemokine receptors.
Conclusions:
We investigated the effect of PACE treatment on muscle flap microcirculation under ischemic conditions. Our results indicate that pre-ischemic and post-ischemic
PACE down-regulated cell adhesion molecules expression and this correlated with reduction of rolling and sticking leukocytes at the microcirculatory level. Postischemic PACE treatment inhibited inflammatory response by: (1) Reducing expression of pro-inflammatory genes such as iNos, Ccl2 and Cxcl5 (p< 0,05); (2)
Maintaining expression of pro-angiogenic genes (eNos and Vwf) and ( 3) Inducing pro-angiogenic gene expression of Vegf (p<0,05). These correlated with
increased expression of pro-angiogenic protein VEGF and capillary density increase, which confirmed potential for neoangiogenesis.
Detection and Classification of Perfusion Differences in a Partial Venous
Obstruction Model Using Near-Infrared Oximetry
Institution where the work was prepared: University of Wisconsin, Madison, WI, USA
John Russell, MS; Mark Kiehn; Nadine Connor; Alejandro Munoz; Gregory Hartig; University of Wisconsin
Background:
Monitoring devices present the opportunity for early detection of vascular problems following microvascular surgery. Near infra-red oximetry is a technology
that provides the opportunity for such monitoring, but the correlation between degree of reduction of vascular flow and clinical signs of vascular insufficiency
have not been thoroughly evaluated. In this study a flap model that permits graded venous stenosis of the vein of a flap’s pedicle is used to evaluate the relationship between venous stenosis or occlusion and tissue oxygen saturation.
Methods:
A porcine model for studying partial venous occlusion was developed previously in our laboratory. In 12 mixed breed pigs, a 7 x 9 cm cutaneous pedicle flap
on the flank was elevated. Animals were equally divided into 3 groups (venous restriction starting points of 20, 40%, and 80%). Near-infrared oximetry (ViOptix,
Freemont, CA) measurements were made following 1 hr congestion periods, in addition to 2 other measures of flap health (quantitative color measures via spectrophotometry and laser Doppler imaging; LDI). Venous restriction levels were then progressively increased. Repeated measures were made until 100% venous
occlusion was obtained for 1 hr. Receiver operating characteristic (ROC) curves were constructed to characterize sensitivity and specificity for assessment of diagnostic accuracy of near-infrared spectroscopy. Cut-off points were calculated from the ROC curves for determination of oxygen saturation (St02) for each level of
venous restriction.
Results:
Excellent diagnostic accuracy for venous congestion was obtained with near-infrared oximetry at each venous restriction level. Average St02 for flaps without
venous restriction was 65 %, while the average for 20% restriction group dropped to 58%. The average for the 40%, 80% and 100% restriction groups
decreased to 56, 36 and 15% St02, respectively (P<.05). ROC analysis indicated that acute restriction of 40% and 80% resulted in less than 54% and 46%
St02 , respectively. With a gradual progression of venous restriction to levels greater than 40% resulted in St02 of less than 42%. Gradual increases in restriction greater than 80% resulted in St02 levels of less than 25%. St02 measures were consistent with spectrophotometric and LDI measures across venous restriction levels.
Conclusions:
Near-infrared oximetry measures made at the skin surface were predictive of actual venous restriction levels and were consistent with other measures of flap
health. Near-infrared oximetry appears to represent a quantitative method for monitoring flap perfusion and for assisting with the determination of the presence of venous congestion.
124
Expanding the limits of macroreplantation; 18 hours forelimb survival of amputated
extremities using extracorporeal perfusion with the heart-lung machine in a porcine model
Institution where the work was prepared: Department of Orthopaedic, Plastic and Hand Surgery, University of Bern, Switzerland
Esther Vögelin, MD, PhD; University of Bern, Inselspital; Mihai Constantinescu, MD; Unversity of Bern
Goal:
Macroreplantations have to be performed within six hours from amputation, to avoid massive reperfusion damage and permanent loss of tissue and function.
Extracorporeal limb perfusion may prolong this replantation window. Following proof of feasibility in a pilot study, the maximal potential of this technique was
investigated in the current study.
Twelve forelimbs of six large white pigs were divided into two groups: I perfusion group, II contralateral cold ischemia group controls. In group I the axillary
artery and two axillary veins were cannulated and extracorporeal perfusion started after 6 hours of cold ischemia. Autologous blood was anticoagulated with
heparin and used for perfusion. Extracorporeal perfusion was performed for 12 hours. Multiple variables including p02, pC02, lactate, potassium, and pH
were monitored by blood gas analysis. Muscular and subcutaneous p02, lactate and temperature were measured by Lycox probes. Muscle contractility was
tested by electrical stimulation. Neurostimulation was used to assess the motor response. The quality of the perfusion at intracellular level was assessed semiquantitatively by morphological analysis of muscle fiber mitochondria using electron microscopy.
Results:
Limb perfusion could be performed continuously for the entire period of 12 hours in all extremities of group I starting after six hours of cold ischemia. pH could
be maintained stable (mean 7.56). Potassium was well controlled with insulin and glucose (mean 6.7 mmol/l). Lactate levels remained high during the perfusion (mean 20.1 mmol/l) due to the lack of the liver in this extracorporeal system. p02 was continuously higher in arterial than in venous blood indicating a
functioning cellular metabolism. Muscular and subcutaneous temperature was constant after initial warming. Full muscle response to stimulation was observed
following a warm-up period of 40 minutes and was reproducible throughout the entire perfusion duration in all extremities after six hours of cold ischemia. In
contrast we found a complete loss of muscle response to stimulation after 20 minutes of cold ischemia in the control group. The ultrastructural analysis paralleled the significant differences between the perfused and the non-perfused extremities.
Conclusions:
The extracorporeal perfusion of amputated extremities demonstrated stable tissue effects at macroscopical, biochemical and histological level. This ex-vivo system successfully maximized the potential replantation period of amputated extremities to 18 hours. The in-vivo effects are currently under investigation.
125
ASRM - Clinical Nerve and Non-Microvascular
Smile Reconstruction Using a Combined Technique of Temporalis Muscle Transfer and
Selective Botulin Toxin in the Treatment of the Long Lasting Unilateral Facial Paralysis
Institution where the work was prepared: PUCRS UNIVERSITY, PORTO ALEGRE, Brazil
Marcos Jaeger, MD, PhD; David Sena, MD; Tomas Bergonsi, MD; Janine Mensch, PT; Pedro Escobar Martins, MD; Jefferson Braga - Silva, MD, PhD, LD;
PUCRS University
Purpose:
Long lasting unilateral facial paralysis (LLFP) is a devastating phenomenon and a challenge for the reconstructive surgeon. Often, the result obtained by a single muscle transfer is not enough to balance with the opposite normal side. The non-affected side looks even stronger in LLFP without the power that should be
expressed by the paralyzed side. The microsurgically transferred segmented muscle is an elaborated technique to return movement to the paralyzed face that
may not be feasible in some circumstances. The aim of the clinical study was to evaluate the functional results of the partial temporalis transfer – TT - combined
with selective botulin toxin injection – BT - in the smile reconstruction.
Method:
16 patients underwent TT for the treatment of the LLFP in the period from 2005 to 2007. All patients had unilateral House-Brackmann V and VI facial paralysis for at least 5 years before specific treatment. Mean age was 49.5 years (10 to 70 years-old), and 14 (87.5%) were female. To obtain a more objective finding, we measured the distance from crista philtralis and mouth corner to the nasogenian sulcus at rest and at movement, before and after operation. Rigid protocol of physiotherapy was assured to all patients. BT was applied to the levator labii superior, zygomaticus minor and zygomaticus major, and to the depressor anguli oris. BT injections started at the third month post-operatively. Statistical analysis was employed using SPSS – version 14.0 to compare the objective
measurements.
Results:
TT expressed contraction at all times in the post-operative period, but only after 5 months post-operatively muscle showed contraction to elevate mouth corner.
This shortened the distance to the nasogenian sulcus elevating the HouseBrackmann score from V- VI to III in 14 of the patients. In two patients with cognitive
problems, the muscle incursion was not enough – House Brackmann IV. Maximum strength was seen after two years of continuous active movement. The utilization of the BT decreased the amount of muscle movement in the normal side.
Conclusion:
The functional result obtained by the utilization of TT combined with BT improved the House-Brackmann classification in all LLFP patients. This was attested by
by the measurement of the distances combination among the anatomic landmarks of the mouth corner, crista philtralis, and nasogenian sulcus. BT helped the
paralyzed side, diminishing the amount of muscle strength in the normal side levator labii superior, zygomaticus muscles, and depressor anguli oris.
Reconstruction of Mandible Defects Using Human Recombinant BMP-2
Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Alex K. Wong, MD; Galen S. Wachtman, MD; Ernest K. Manders, MD; University of Pittsburgh Medical Center
Background:
Traditional methods of reconstruction of segmental mandibular defects involves the use of reconstruction plates in combination with non-vascularized bone
grafts, vascularized bone grafts, and pedicled or free flaps. Drawbacks to these methods include donor site morbidity as well as lengthy operative and recovery times. In this paper, we present an alternative method of mandible reconstruction using human rhBMP-2 (Infuse - Medtronic, Minneapolis, MN).
Methods:
Six patients with mandibular defects ranging from 4 to 10 cm have had rhBMP-2 mediated reconstruction by the senior author. Both intraoral and extraoral
approaches were used. After exposure of the mandible and application of a reconstructive plate, a bone graft “sandwich” consisting of 12.5 mg rhBMP-2, 9
ml tricalcium phosphate putty moistened with blood, and an enveloping collagen sponge was inserted into the defect. Layered closure over drains was performed. Postoperatively, patients were followed with CT scans and physical examination for surgical complications including dehiscence and infection.
Results:
Charts were reviewed for all patients. Follow-up intervals ranged from one to nine months postoperatively. Radiographic evidence of new bone formation was
observed as early as one month postoperatively. Clinical examination revealed solid bone formation at three months. Complications have been limited to intraoral wound dehiscence requiring re-operationg (n=1). Currently, several patients are being evaluated for osseointegrated implants for dental reconstruction.
Conclusions:
Sucessful reconstruction of segmental mandibular defects with rhBMP-2 is possible. Further investigation is warranted for long-term acceptance of this alternative reconstructive paradigm.
126
Reconstruction of Pelvic Exenteration Defects with the Anterolateral Thigh-Vastus
Lateralis Muscle Flaps
Institution where the work was prepared: University of Texas, M.D. Anderson Cancer Center, Houston, TX, USA
Sarah Hew-Ming Wong, MD; University of Texas, M.D. Anderson Cancer Center; Peirong Yu; The University of Texas M. D. Anderson Cancer Center
Purpose:
The rectus abdominis flap may be unavailable or insufficient to reconstruct large pelvic exenteration defects. We report our experience with an anterolateral
thigh-vastus lateralis muscle (ALT-VL) flap for such reconstructions.
Methods:
Eighteen consecutive patients with pelvic exenteration by a single oncologic surgeon were reconstructed with a pedicled ALT-VL flap by a single plastic surgeon
between 2003 and 2007. Two techniques were used to transfer the flap to the defects. When the perineal defect could be closed primarily with minimal tension, the VL muscle flap was tunneled over the inguinal ligment into the pelvis (inguinal route). When concomitant perineal-vaginal reconstruction is needed,
the ALT-VL flap was tunneled over the medial thigh to the defects (perineal route).
Results:
There were five male and thirteen female patients with a mean age of 58±10 years and mean body mass index of 27±5. All patients received preoperative chemoradiation with a mean dose of 49 ±7Gy. Nine patients also received intraoperative brachytherapy to the pelvis. Eleven patients had recurrent cancer in the pelvis following previous resection, of which ten patients already had a colostomy and three had a parastomal hernia. After pelvic exenteration this time, all patients had a
colostomy and eight had a urostomy with ileal conduit. Six patients also required sacrectomy and coccygectomy and four had exposure of iliac vessels. Perineal
defects were closed primarily in six patients and the VL flap was brought to the pelvis via the inguinal route. The perineal route was used in ten patients. In the
remaining two patients, the ALT-VL flap from one thigh was brought to the defect via the perineal route and another VL flap from the contralateral thigh was brought
to the pelvis via the inguinal route. Postoperative complications included a small perineal wound dehiscence in 5 patients which healed spontaneously. One flap
died due to tension on pedicle in an obese patient with a short thigh leading to abscess which was drained and reconstructed with another ALT-VL flap. One patient
developed enterocutaneous fistula and another, ileal conduit leak which healed spontaneously. No ventral or inguinal hernias occurred.
Conclusions:
The ALT-VL flap is a good alternative for reconstruction of large pelvic exenteration defects when the rectus abdominis flap is either inadequate or unavailable.
Obese patients with a short thigh (the distance between the anterior superior iliac spine and the superolateral corner of patella < 42cm) may not be good candidates for this procedure.
The Pedicled Peroneal Artery Perforator Flap for Soft Tissue Coverage of the Leg and Foot Defects
Institution where the work was prepared: Chang Gung Memorial Hospital, LinKou, Taiwan
Ting-Chen Lu, MD; Cheng-Hung Lin, MD; Ruei-Feng Chen, MD; Yu-Te Lin; Chih-Hung Lin; Chang Gung Memorial Hospital, LinKou
Background:
The lower-third of the leg and foot remains a challenging area in regard to soft tissue coverage, because of the paucity of local cutaneous and muscle flaps in
this area. Even a small defect in this region may justify the need for a microsurgical tissue transfer to achieve coverage, because the common exposure of bone
and tendons results in a chronic, intractable wound. With the concept of the perforator flap, the authors describe a peroneal artery perforator–based flap for
coverage of this difficult region, and furthermore, propose a classification scheme for this type of flap.
Between November 2002 and May 2008, 15 pedicled peroneal artery perforator flaps were performed in 15 patients. Ages ranged from 16 to 82 years with
a mean of 53.2. The fasciocutaneous flaps were employed to cover defects in the pretibial area (5), hind foot (6), lateral malleolar area (3) and anterior ankle
(1). Exposure of bones or/and tendons was noted in all wounds.
Results:
The pedicled peroneal artery perforator flaps are classified into five types, including propeller flap (n=11), peninsular flap (n=2), advancement flap (n=1), proximally based flap (n=1), and distally based flap (n=0). The size of the perforator-based flaps ranged from 2.5 x 4 cm to 8 x 20 cm. The selected perforator
depended on the defect location, ranging from 4.5 to 18 cm above the tip of the lateral malleolus. Postoperative venous congestion was encountered in five
propeller flaps. Venous congestion subsided within days without complications, except one which needed further reconstruction with skin graft.
Conclusion:
The peroneal artery perforator is predictable and reliable for the design of a perforated-based flap. It has three main advantages. First, it is thin and has good
cosmetic results because of its nice contour. Second, elevation of the flap can be performed easily in the supine or prone position, depending on the defect location. Third, the flap can be designed on a chimerical concept. A muscle flap can be included for obliteration of the dead space. Venous congestion is the main
complication. To reduce strain on the vein, the perforator should be mobilized carefully to obtain an adequate length when designing propeller flaps. The pedicled peroneal artery perforator flap is a useful method to achieve soft tissue coverage of the leg and foot defects. In many instances, it has obviated the need
for free tissue transfer.
127
The Pedicle Descending Branch Muscle-sparing Latissimus Dorsi Flap for Breast Reconstruction
Michel Saint-Cyr, MD; Purushottam Nagarkar; Mark Schaverien; Phillip Dauwe; Corrine Wong; Rod J. Rohrich; UT Southwestern Medical Center, Dallas
Background:
The pedicled descending branch muscle-sparing latissimus dorsi flap with a transversely oriented skin paddle presents distinct advantages in breast reconstruction, including reduced donor site morbidity and greater freedom of orientation of the skin paddle. This study reports the anatomical basis, surgical technique, complications, and
the aesthetic and functional outcomes following use of this flap for breast reconstruction.
Methods:
A retrospective study of 20 patients who underwent breast reconstruction with a pedicled muscle-sparing latissimus dorsi musculocutaneous flap was conducted. Indications
for surgery included breast reconstruction following mastectomy, following lumpectomy and radiation and for correction of implant related complications. Case-note review
was performed, as well as functional evaluation consisting of a patient questionnaire, a DASH form, post-operative range of motion analysis, and instrumented strength
testing comparing the operated and non-operated sides. Aesthetic evaluation of the donor site was conducted by all patients. An anatomical study of fifteen flaps harvested from fresh cadavers was performed to determine the location of the bifurcation of the thoracodorsal artery and the course of its descending branch.
Results:
Twenty-four descending branch muscle-sparing latissimus dorsi flaps were harvested. All donor sites were closed primarily, with skin paddle sizes ranging up to 25x12cm.
There was one case of minor flap tip necrosis and no incidences of seroma. There was no statistically significant difference in strength or range of motion of the shoulder
joint when comparing the operated to the non-operated side. Two patients reported minor functional impact following surgery.
Conclusions:
The pedicled descending branch muscle-sparing latissimus dorsi flap with a transversely orientated skin paddle results in minimal functional deficit of the donor site,
absence of seroma, large freedom of orientation of the skin paddle, low rate of flap complications, and a cosmetically acceptable scar.
Use of Pedicled Subpectoral Fascia Flap for Expander Coverage in Post-Mastectomy Breast Reconstruction – A Novel Technique
Hema Thakar, MD; Michel Saint-Cyr; Purushottam Nagarkar; Phillip Dauwe; Corrine Wong; Rod J. Rohrich; UT Southwestern Medical Center at Dallas
Background:
In expander based breast reconstruction, providing adequate tissue coverage of the prosthesis is necessary to prevent complications. Placing the expander in a subpectoral pocket may not provide sufficient lateral coverage. Furthermore, inferior release of the pectoralis major to achieve a natural breast ptosis can result in inadequate
inferior coverage. In these situations, several muscle, fascial, and allograft options are available for providing adequate expander coverage. The serratus anterior fascia
can be used for this purpose but when this fascia is unavailable or inadequate, the subpectoral fascia can be used. This study describes the anatomy of the subpectoral
fascia flap, the surgical technique for harvesting it, and an algorithm for choosing between the serratus and subpectoral fascia flaps. Clinical and functional outcomes following use of the subpectoral fascia in expander-based breast reconstruction are reported.
Methods:
An anatomical study of ten subpectoral fascia flaps was conducted using fresh cadavers to determine the size, vascularity, and anatomical landmarks of the subpectoral
fascia flap. Thirteen patients (17 breasts) were included in the study. After approval by the Institutional Review Board, retrospective case note analysis was performed for
demographic and perioperative factors. Postoperative complications including capsular contracture, seroma, hematoma, wound dehiscence, and infection were recorded.
Results:
Mean cadaver flap width was 7.6 cm (range: 4.2-12.4 cm) and mean flap length was 13.8 cm (range: 120-170 cm) for a mean surface area of 105 cm2. At mean follow-up of 182 days (range 71-276), seroma occurred in one breast, minor wound infection in one breast, and minor wound dehiscence in one breast. There were no
incidences of capsular contracture or hematoma.
Conclusion:
The subpectoral fascia flap is a novel and safe option for providing vascularized lateral or inferior coverage of prosthesis in expander-based breast reconstruction. Its harvest and use is not associated with adverse clinical outcomes
128
Single-Stage Reconstruction of Massive Damage Control Abdomen Using a Vicryl Mesh Buttress
Theresa Y. Wang, MD; River Elliott, MD; Benjamin Chang, MD; University of Pennsylvania
Purpose:
Damage control laparotomy has become an accepted approach for patients with life-threatening abdominal conditions. While this protocol increases survival, it compromises abdominal fascial integrity resulting in massive hernia. This is functionally and aesthetically debilitating. We present our outcomes with these complex abdominal
wall reconstructions which represents the largest reported series of hernia repairs with defects of this sized magnitude.
Methods:
A prospective review was conducted of 56 patients with previous damage control laparotomies (13F, 43M) who underwent elective single-stage reconstruction between
1999 and 2006. Mean age was 42 years (19 to 80). Reconstruction in all patients consisted of a double-layer, subfascial Vicryl mesh buttress to aid in establishing abdominal wall integrity, combined with components separation and rectus muscle turnover flaps. The average cost of the vicryl mesh was $606/ sheet or approximately 67¢/sq
cm. Activity and functional levels were evaluated by clinical exams and telephone surveys.
Results:
Major etiologies of abdominal hernias were gun-shot wounds (36.2%), motorvehicle accidents and blunt trauma (23.4%) and sepsis or perforated bowel (23.4%). The mean
abdominal wall defect was 865cm2 (150 to 2475), and the average interval time to definitive repair was 16.9 months (3 to 41). Average length of follow-up was 29 months
(1 to 95). Recurrent herniation following definitive repair was 12.5% (7/56). Of these, one was successfully repaired and the rest were small umbilical hernias that were asymptomatic and did not limit function. Other complications include superficial skin dehiscence, all of which healed secondarily with daily wound care 8.9% (5 patients) and abdominal compartment syndrome 7.1% (4 patients). There were no mesh exposures, or seromas. There were two post-operative mortalities in the initial part of the series, both which
occurred with compartment syndrome and were reopened in the intensive care unit. Fifty-three percent completed follow-up telephone surveys, and 90% who worked full-time
prior to injury returned to their jobs, and 92.3% were functioning at pre-trauma activity levels.
Conclusion:
Massive abdominal hernia following damage control laparotomy poses a great challenge to the reconstructive surgeon. This patient population is at significant risk for mortality and morbidity. We present the largest series of repairs of these massive hernias with long-term follow-up and an acceptable hernia recurrence rate. Functional results are
excellent with most returning to work and at normal activity levels. We believe the use of a vicryl mesh buttress is an important adjunctive and cost-efficient maneuver for definitive, single-stage complex abdominal wall reconstruction.
Figure 1: This is a 53 year-old female after a motorvehicle collision with a hemia size of 1836cm2, and this is 4 months
post-repair. She has returned to full-time work.
Figure 2: This is a 54 year-old female who suffered from perforated diverticultis with hernia size measuring 1125cm2. This
is 4 months post-repair, and she has since returned to full-time work. we spoke to her 6 years after her repair - she has
no physical limitations and is able to exercise.
Versatility of Perforator Propeller Flaps: A Creative Approach for Reconstruction
Institution where the work was prepared: Universite de Montreal, Montreal, Canada
Catherine Lecours, MD1; A. Gagnon2; C. Bernier2; Emile Mailhot3; Jenny C. Lin4; M. Tardif4; A. Chollet4; (1)Universite de MOntreal, (2)CHUM Pavillon Notre-Dame,
(3)Universite de Montreal, (4)Hopital Maisonneuve-Rosemont
Background:
Over the past decade, our understanding of perforator vessels has evolved, leading to increased use of perforator flaps for reconstruction in general. These flaps offer
reliable soft tissue coverage without the functional loss associated with musculocutaneous flaps. We believe that the use of perforator flaps as free tissue transfer has overshadowed their potential use as pedicled flaps. In our opinion, pedicled perforator flaps offer more choices of local reconstructive options, because of the wide availability of feeding vessels in any anatomical location. The pedicled perforator flap can be designed as a propeller which consists of an elliptical shaped-flap, based on an
eccentric perforator. The propeller flap allows possible three hundred and sixty degrees coverage around its pedicle and also contributes to closure of the donor site. This
flap design can also increase the reach of these local perforator flaps, thus increasing their versatility.
Purpose:
To demonstrate the versatility of perforator propeller flaps and their use as an alternative to free flaps.
Method:
A case series of multiple soft tissue defects of various locations and sizes were reviewed (n=18). These defects were all reconstructed with pedicled propeller flaps.
Results:
Flap survival and complete coverage of the defects were obtained in sixteen of our eighteen cases. In one case, a very large lumbar propeller flap showed superficial
sloughing of the distal tip that heeled by secondary intention. Two total flap failures occurred, both in high risk patients. The first case involved an internal mammary artery
perforator propeller flap for reconstruction of a sternal defect. The flap was clinically well vascularised in the immediate post-operative period. The patient then developed
post-operative cardiac failure which required high-dose vasopressors. In the second case, a posterior tibial artery perforator propeller flap was used for coverage of an
heel defect in a diabetic patient with chronic renal failure who had previously undergone BK amputation of the contralateral leg for vascular disease.
Conclusions:
Propeller flaps constitute a novel approach for the closure of complex defects. Their main advantages are that there is no need for microsurgery, it is technically easier and
these procedures are possible despite limited resources. Because of its many advantages and versatility, we feel that the perforator propeller flap will find its place as a
valued option in the classic reconstructive ladder.
129
Refining Donor Criteria for Hand Transplantation
Institution where the work was prepared: Christine M. Kleinert Institute, Louisville, KY, USA
Kv Ravindra, MD; Jewish Hospital; C. Kaufman, PhD; Christine M Kleinert Institute; Wc Breidenbach; Kleinert Kutz and Associates
Background:
With increasing success in solid organ transplantation, donor criteria have become far more liberal over the past decade. There is data to support the use of organs from extended criteria donors. Hand transplantation is still in infancy and there has been little discussion about donor quality.
Methods:
Utilizing data from solid organ transplantation, we have refined our inclusion and exclusion criteria for hand donors.
Results:
Size, age and color matching should play a primary role in donor selection. Medical illness such as hypertension, renal failure, diabetes and ischemic heart disease are
markers for atherosclerosis and should be factored in hand donors. If there is any question, these donors should not give CTA grafts. Donors with HIV and Hepatitis C,
viral encephalitis, history of malignancy (other than certain intracranial neoplasms), recent high risk behavior, inherited or metabolic neuropathy, rheumatoid arthritis etc.
are absolute contraindications. Hepatitis B core antibody positive donors may be used in recipients immunized for Hepatitis B. In contrast to solid organ transplants where
biochemical indices or biopsies provide clues to degree of damage in unstable donors, there are no parameters to assess the hand. Non-heart beating donors should be
considered for hand transplantation. The premise is that the warm ischemia time of composite tissues is longer than solid organs.
Conclusions:
The criteria for identifying hand donors need to be made liberal. The extended criteria listed above may help increase the donor pool for hand transplantation.
Composite Tissue Transplantation: Are Concerns about Over Immunosuppression Unwarranted?
Institution where the work was prepared: University of Louisville, Jewish Hospital Transplant Center, Louisville, KY, USA
Jf Buell, MD1; Kv Ravindra, MD1; M. Marvin1; R. Nagubandi1; B. Blair2; Cl Kaufman, PhD1; Wc Breidenbach, M1; (1)University of Louisville, (2)Christine M Kleinert Institute
Technical issues in hand, tracheal and partial face transplantation have been overcome in the last decade. Despite surgical proliferation of these procedures, significant
concerns have been raised over the impact of chronic immunosuppression. We set forth to address the relationship of immunosuppressive therapy and chronic sequalea.
Methods:
We examined on management of three unilateral hand-forearm transplants over a ten year period and address several issues of chronic immunosuppression.
Results:
Our observation that two patients suffered systemic CMV and that rejections were spotty. With normal adjacent tissue and normal allograft function we treated pts with
topicals agents (tacrolimus and steroids) with resolution of grade I, II and even III rejections. This led to rapid steroid elimination under campath induction in one pt and
steroid withdrawal in the remaining two. To risk factors associated with chronic rejection 1) cardiovascular risk 2) infection 3) cancer 4) bone loss we assessed our pts
Framingham criteria.
Tx 1
Tx 1-post
Tx 2
Tx 2-post
Tx 3
Tx 3- post
1 yr
Date
Pre
9 yrs
Pre
6.8 yrs
Pre
Age
37
46
36
43
54
55
LDL
85
42
84
121
142
81
HDL
50
44
60
63
50
34
BP
132/82
128/70
134/80
120/80
132/78
130/88
DM
Y
Y
N
Y
N
N
Smoker
N
N
N
N
N
N
CDRP score (%)
2(4%)
2(4%)
-4(<1%)
2(4%)
4(7%)
4(7%)
Since the elimination of steroids and the minimization of re-induction or high calcineurin inhibitor levels (CNI) we have eliminated any further episodes of CMV. We currently have not identified any cases of malignancy in our pts but closely adhere to the ACS guidelines. All patients now undergo baseline dexa scans to assess bone density. All patients are within the one standard deviation of the expected density. In assessment of renal function, calculated GFR was performed over time. This demonstrated a decrease of GFR during the first month post-transplant when CNI levels were run high. Subsequent 24 hr collections were made to measure GFR. In the two patients
with long-term follow-up their GFRs increased after one year to a level just below their baseline.
Conclusions:
In our experience with CTA hand allografts, we believe CTA patients have been woefully over immunosuppressed. The concept of spotty rejection, clinically evident rejection and rapidly reversible rejections solely with topical immunosuppressive agents is novel. Currently we have minimized our patients’ immunosuppression and have confirmed reasonable risk profiles.
130
End-to-Side Versus End-to-End Ulnar Nerve Transfer in Upper Trunk Brachial Plexus Lesions
Institution where the work was prepared: PUCRS University, Porto Alegre, Brazil
Marcos Jaeger, MD, PhD; Jefferson Braga-Silva; Javier Roman, MD; Mónica Rodrigues, MD; PUCRS University
Objectives:
After brachial plexus lesions, muscle bulk may be preserved by re-established innervation. However, often no motor nerve may be utilized without donor sequelae. The Oberlin procedure has been designed to provide biceps restablishment without donor nerve impairment. This neural transference is not advised in
patients presenting with C5-T1 lesions. The aim of this study was to assess end-to-side ulnar to biceps branch of musculocutaneous neurorraphy in restoring
elbow flexion.
Method:
A experimental study with twenty Wistar rats were initially designed. The rat medial gastrocnemius was transposed and wrapped with Silastic® to prevent neural contamination and modalities of end-to-side and end-to-end with motor and sensory nerve were studied. After 16 weeks, muscles were collected and compared in wet weight and histology. End-to-end and end-to-side motor nerve groups had much less atrophy(p>0,05) compared to control. From 2003 to 2006,
we delineated the clinical research in eight men referred for brachial plexus lesion treatment. Mean age was 26.4 +/- 10 years. Surgery was performed 3.8
+/- 1.6 months postinjury (+/- SD, range 2.5-7.5 months). The Oberlin procedure was employed in 4 patients (Group 1), and end-to-side neurorraphy
between biceps branch and ulnar nerve was employed – 4 patients(Group 2). These patients initially presented with total brachial plexus palsies but recovered
ulnar function. The British Medical Research Council (BMRC) score was evaluated to obtain a functional result.
Results:
Evidence of biceps reinnervation was clinically noticed at 5.3 +/- 2 months postoperatively (+/- SD, range 1-8 months) and the mean length of follow-up was
19.3 +/- 15 months. Elbow flexion strength reached BMRC grade 4 in three patients of Group 1 and BMRC 2 in four patients of Group 2. No weakness in
ulnar nerve or diminished sensation were reported in either group.
Conclusion:
The Oberlin procedure provided a reliable source of donor motor axons for transfer in brachial plexus injuries and allowed return of biceps function in timely fashion
without functional donor sequelae in group 1. After end-to-side (group 2), the quantity of functioning motor axons has not been sufficient for satisfactory recovery
(median=2). However, it may contribute for maintaining muscle trophysm with no donor nerve impairment.
Refinements in Targeted Reinnervation in Transhumeral Amputees: Proximal Radial
Nerve Anatomy and Advancements in Operative Technique
Jason H. Ko, MD1; Peter S. Kim, MD1; Kristina D. O’Shaughnessy, MD1; Christopher J. Wilson, MD2; Todd A. Kuiken, MD, PhD3; Gregory A. Dumanian,
MD1; (1)Northwestern University Feinberg School of Medicine, (2)Brooke Army Medical Center, (3)Rehabilitation Institute of Chicago
Background:
Targeted reinnervation effectively improves myoelectric prosthesis control in transhumeral amputees; however, our original technique requires a long residual
limb and the presence of the brachialis muscle—a limiting factor for many amputees. We have since improved our technique and expanded our patient criteria for eligibility, allowing more amputees to undergo this simplified procedure.
Methods:
Five transhumeral amputees with a mean age of 31 (range 22-38) underwent a modified targeted reinnervation procedure at a mean duration of 17.1 months
(range 3.9-30.1 months) after initial amputation. The median nerve was transferred to the motor nerve coming off of the musculocutaneous nerve as it entered
the medial head of the biceps, as we have previously reported. For the radial nerve, our new transfer takes the distal end of the amputated radial nerve and
transfers it to the motor branch to the lateral head of the triceps—this transfer is based on cadaver dissections that analyzed the branching patterns of the proximal radial nerve to the long and lateral heads of the triceps. Another modification of the procedure was to create vascularized adipofascial flaps to separate
and improve detection of myoelectric signals between adjacent muscle bellies. Patients were previously excluded if duration between injury and surgery exceeded 1 year, but we have since expanded this duration to 3 years. At this time, we have also performed procedures in 2 more transhumeral amputees, but due
to their limited follow-up duration, these patients were not included in this report.
Results:
Of the 10 nerve transfers performed, 9 have been completely successful over a mean follow-up period of 10.3 months (range 10-21.6 months). One median
nerve transfer to the medial head of the biceps has a diminished signal at 6.5 months, but already the signal is effective and will most likely improve over time.
In addition, 3 of the 5 patients have working myoelectric prostheses at this time.
Conclusion:
A better understanding of the proximal radial nerve anatomy, along with other modifications, has allowed us to successfully perform targeted reinnervation in
patients with amputations at the level of the middle-to-distal thirds of the humerus, which was not possible with our original technique.
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ASRM - Clinical Extremities I
Functional Assessment of Microsurgical Heel Reconstruction Due to Landmine Explosions
Fatih Zor; Levent Tekin; Ismail Safaz; Serdar Ozturk; Mustafa Deveci; Selcuk Isik; Gulhane Military Medical Academy
Introduction:
Landmine injuries generally results in composite tissue defects including both the soft tissues and the bones. The heel and ankle has special anatomic design
which makes it almost impossible to perform an ideal reconstruction. The functional outcomes of are needed to be discussed. The aim of this study is to evaluate the functional outcomes of heel reconstructions due to landmine explosions.
Nineteen patients who had lower extremity injuries due to landmine explosions were included in the study. The age of the patients were between 24-32 years.
All patients were reconstructed with free muscle flaps. The control group included 9 patients with similar characteristic features. Functional Ambulation Scale
(FAS), visual analogue scale (VAS), short form 36 (SF-36) energy expenditure index (EEI), 6-minute walking test (6MWT) and 10-meter walking test (10MWT)
were used for the evaluation of subjects. Patients in the reconstruction group were also evaluated radiologically with Graves’ radiological assessment method
and Freiburg ankle scoring system.
Results:
Mean VAS scores were found to be statistically similar in two groups (p>0.05). Mean Freiburg ankle scores of the patients in the reconstruction group was
55.33±15.51 which was consistent with moderate functionality. Graves’ radiological assessment showed a moderate ankle joint degeneration. Mean EEI values, 6-MWT and 10-MWT results were indifferent between the groups (p >0.05). The Functional Ambulation Scale showed no difference between the groups.
The SF-36 test showed that the general health status and vitality of the reconstruction group were lower (p<0,032 and p<0,006 respectively).
Conclusion:
According to our results, the functional capacity of the reconstruction group seems to be adequate in terms of daily life. Despite the ankle degeneration, there
were no difference in terms of walking parameters, energy expenditure index, VAS and FAS, showing good ambulation. Although there was no significant difference concerning functionality; we think that this may be partly due to the age of our patients. The patients are young and all has good physical capacity
and it is easy for them to compensate their functional loss. We think that the same assessment must be performed when the patients gets older.
Lower Extremity Arterial Injury Patterns in Patients Requiring Free Flap Reconstruction:
A Fifteen Year Review
Nicholas Haddock, MD; Katie Weichman, MD; Evan Garfein, MD; Daniel J. Ceradini, MD; Jamie Levine, MD; Pierre B. Saadeh; New York University
Langone Medical Center
Background:
The management of severe traumatic lower extremity injuries remains a considerable challenge. Whereas the literature is replete with descriptions of free tissue transfer options, there are no comprehensive reports of arterial injury patterns in patients requiring free flap reconstruction. Since we obtain routine angiography in these cases, we undertook a review of our experience in order to gain insight on vascular injury patterns and surgical outcomes.
Methods:
A 15 year retrospective analysis of all microvascular free flaps performed for traumatic injuries to the lower extremity at Bellevue Hospital, NYU Hospital, and
the Manhattan VA was performed. Patient demographics, Gustillo classification, angiographic findings (conventional/MRA) where injury was defined as no
flow, recipient vessels, elapsed time from injury, and flap choices and outcomes were examined.
Results:
Eighty-seven free flaps on 71 patients were performed from March 1993 until March 2008. There were 55 males and 16 females ranging from age four to
83 (median age 30). Patients sustained either Gustillo IIIb (64 patients) or IIIc (seven patients) open fractures. Sixty patients had angiograms (83% IIIb, 100%
IIIc); angiography not performed in select cases (contraindication to contrast, immediate reconstruction, etc). Twenty-seven (45%) had normal three-vessel runoff
and 33 (55%) were abnormal. Of the abnormal angiograms; 15 patients had injury to the anterior tibial (AT), 11 patients had two vessel injuries (10 AT and
peroneal (P), one posterior tibial (PT) and P), five patients had injured popliteals, three patients had injured PTs, two patients had injuries to all three vessels.
Recipient vessels included PT (50), AT (25), popliteal (five), P (three), sural artery (two), and local perforators (two). Free flaps used included 41 rectus abdominus, 23 lattissimus dorsi, 10 fibula, seven gracilis, three anterolateral thigh, two parascapula, and one serratus anterior. The elapsed time from injury to reconstruction ranged from immediate to two years (median time eight days). Flap-related outcomes included flap failure (eight), need for subsequent flap revision
(12), need for additional free flap (three), and need for subsequent skin graft (nine).
Conclusions:
Angiography of severe lower extremity injuries requiring free flap reconstruction usually revealed arterial injury. When determining injuries and choosing recipient vessels, it is our experience that the AT is most commonly injured and the PT is most likely to be spared and used as a recipient vessel for free flap reconstruction.
132
Quantifying the Advantage of Vascular Studies in the Pre-operative Evaluation of
Recipient Vessels in Lower Extremity Reconstruction
Institution where the work was prepared: University of Montreal, Montreal, QC, Canada
Photis Loizides, MD1; David Mok2; V. St-Supéry, MD2; Patrick Harris2; Andreas Nikolis2; C. Guertin2; (1)McGill University Health Centre, (2)University of Montreal
Introduction:
Free tissue transfer for lower extremity reconstruction has been associated with higher failure rates than other locations. Often, this is due to the presence of
poor recipient vessels. This presents the challenge of adequately identifying suitable recipient vessels for free tissue transfer when local options are unavailable
and limb salvage is attempted. We propose an algorithm for identifying patients that will benefit from vascular studies prior to free tissue transfer, and for quantifying the availability of recipient vessels based on clinical examination.
Methods:
The results of vascular studies of 404 lower limbs from 224 randomly selected patients undergoing studies between 1998 and 2008 were retrospectively examined. Triphasic flow on Doppler is the equivalent of a clinically palpable pulse and is indicative of good arterial flow. The equivalent of lower extremity pulses
were thus correlated with vascular study results to quantify specific vessel availabilities.
Results:
In those extremities in which either the dorsalis pedis (n=15) or the tibialis posterior (n=78) had triphasic flow, 61% (n=57) had triphasic flow in the peroneal
arteries. In addition, these same extremities have at least one other vessel with biphasic flow or better. In extremities without triphasic flow in either artery (n=75),
only 13% had triphasic flow in the peroneal artery (n=10). Again in all of these extremities, at least one artery had biphasic flow or better.
Conclusion:
Patients with intact popliteal but absent dorsalis pedis and posterior tibial pulses are undoubtedly candidates for pre-operative vascular studies if free tissue
transfer is contemplated, as only 13% have a peroneal artery that can be safely used as a recipient vessel. We also recommend the use of vascular studies in
patients with a single intact foot pulse. Approximately 39% of these patients will not have an adequate peroneal artery and therefore an end-to-side anastomosis on the pulsating vessel remains the safest option for free tissue transfer. However, all of these patients actually have a biphasic Doppler flow in at least
one other vessel which means that adequate foot perfusion will likely be maintained if the dominant pulsating vessel is lost. Patients with both foot pulses intact
don’t require further investigations as either the anterior or posterior tibial arteries can be used as recipient vessels with no concern for eliciting distal ischemia.
Distal Lower Extremity Reconstruction with 180-degree Perforator-Based Propeller
Flaps: Microsurgery without the Anastomosis
Institution where the work was prepared: The Johns Hopkins University School of Medicine, Baltimore, MD, USA
Ariel N. Rad, MD, PhD1; Michael R. Christy, MD2; Eduardo D. Rodriguez2; Julie E. Park, MD2; Jonas A. Nelson2; Anshuman Bansal1; Gedge D. Rosson,
MD1; (1)Johns Hopkins University School of Medicine, (2)R Adams Cowley Shock Trauma Center
Background:
Distal lower extremity soft tissue defects are routinely managed with free tissue transfer due to limited local options. Propeller flaps are defined by 180-degree
rotation about a single perforator axis. They are powerful alternatives due to their predictable vascular territory, axial perfusion, and liberal arcs of rotation,
allowing coverage of a greater surface area without sacrificing a major vessel. Small (< 20 cm2) fasciocutaneous propeller flaps have been described, however there are limited published data on large (> 40 cm2) fasciocutaneous and muscle propeller flaps following tumor extirpation, trauma, or infection.
We conducted a multi-center IRB-approved retrospective review of lower extremity propeller flaps based on the tibialis anterior, tibialis posterior, and peroneal
vessels. Demographic, peri-operative, and outcomes data were collected. Additionally, 15 fresh, latex-injected cadaver legs were dissected to define perforator anatomy, including: number, dominance, location, landmarks, and pedicle length.
Results:
Ten patients underwent perforator-based 180-degree propeller flap reconstruction between 2006 and 2008. The indications for reconstruction were trauma
(n=6), osteomyelitis (n=2), and tumor extirpation (n=2). Defect location included: knee/popliteal fossa (n=2), proximal tibia (n=3), distal tibia (n=1),
malleolus/Achilles (n=4). Nine flaps were single-staged reconstructions and 1 was delayed. Mean flap surface area was 122 cm2. Two patients had propeller
flaps to salvage failed gastrocnemius flaps. There was 1 partial flap loss requiring free tissue transfer and 3 with distal tip necrosis (< 5%) with no adverse
sequelae. One patient required an amputation for overwhelming infection, unrelated to the flap. Nine of 10 flaps (90%) healed uneventfully with a mean follow up of 11.7 months. Anatomic dissections confirmed a single dominant perforator from the tibialis anterior vessel 12 +/- 1.7 cm distal to the mid-lateral
patella; mean pedicle length was 8.2 +/- 1.8 cm. A dominant perforator from peroneal vessels was located at 13.2 cm +/- 2.0 cm proximal to the lower border of the lateral malleolus; mean pedicle length was 5.5 +/- 1.5 cm. A minor distal perforator was located in 60% of dissections at 8.0 cm. A posterior tibial perforator to the soleus muscle was located at 7.5 cm proximal to the medial malleolus.
Conclusions:
Perforator-based propeller flaps provide reliable and versatile coverage of the distal lower extremity. Anatomic confirmation of their predictable vascular territory allows superior surface area coverage via liberal arcs of rotation. This approach empowers the reconstructive surgeon by increasing freedom in flap design
and execution without sacrificing a major vessel.
133
IVaS Technique for Various Type of Lymphatico-Veous Anastomosis(LVA)
Institution where the work was prepared: Tokyo university department of plastic & reconstructive surgery, tokyo bunkyo-ku hongo 7-3-1, Japan
Mitsunaga Narushima; Isao Koshima; Makoto Mihara; Jun Araki; Yusuke Yamamoto; University of Tokyo
Purpose:
There are a lot of patients with lymphedema in the world. In the surgical methods, it is no exaggeration that lymphatico-venous anastomosis (LVA) is an effective and less invasive surgical solution. This method needs to use a super-micro surgical technique. But because of the difficulty of techniques, various other
methods are still widely used. Recently reversed flow from proximal lymphatic channel has proved. So we aggressively have performed flow-through and end
to side lymphatico-venous anastomosis, sometimes double end to end, side to side or g type anastomosis. On this paper, we will report about various type of
LVA using intravascular stenting (IVaS) method
We performed lymphatico-venous anastomosis for both sides of lymphatic channels. The strategy is as follows. First lymphatic channel and Y shape vein are
detected, and both sides of lymphatic channel and proximal side of Y shape vein are anastomosed. It’s called flow through anastomosis. If Y shape vein does not
find, the proximal side of vein is anastomosed to the sidewall of lymphatic channel. In fact end to side LVA is performed. When the diameter of vein is over twice
as large as lymphatic channel, both sides of lymphatic channel are anastomoses the sidewall of vein each. (anastomosis) For various applications of anastomosis like this, we performed LVA using intravascular stenting (IVaS)method.
Results:
IVaS size range varied from 4-0 to 6-0, and the range of IVaS length was 5-20mm. There were no cases in which the vessel and lymphatic channel back wall
was inadvertently caught, an event that would have required reanastomosis. 34 LVA with IVaS were performed in 21 patients at Tokyo University Hospital. All
patients were female. The LVA comprised 13 end to end , 11end to side, 7 flow-through, 2  , and 1 side to side anastomosis.
Conclusions:
For lymphedema,various conservative treatments have reported. But surgical methods are very few. We performed various types of LVA using IVaS. These LVA
methods are effective and less invasive surgical solutions for lymphedema patients.
Microsurgical Soft Tissue Reconstruction with Temporary Arterio-Venous Loops
and Free Tissue Transfer
Marcus Spies; Christian B. Herold, MD; Gerrit Wunsche, BS; Karsten Knobloch, MD, PhD; Peter M. Vogt; Hannover Medical School
Introduction:
After extensive soft tissue trauma or radical tumor resection in extremities there may only remain an inadequate vascular situation for subsequent soft tissue
reconstrcution with free tissue transfer. By using a temporary av-loop microvascular anastomoses may be performed in a safer and easier manner, leading to
an improvement of the local vascular situation and perfusion of th etransferred flap.
Between June 2001 and December 2007, a temporary av-loop was necessary in 18 patients due to an inadequate vascular situation prior to microvascular
soft tissue transfer. In the head and neck region we used the pedicled brachio-cephalic vein or the greater saphenous vein, in the pelvic region the pedicled
greater saphenous vein, in the lower leg the greater saphenous vein to form a temporary av-loop.
Results:
In 7 patients a simultaneous free tissue transfer was performed with the av-loop, in 11 patients staged free flap transfer was performed 4 to 17 days after the
av-loop. Revision surgery was needed in 5 cases (2 with simultaneous, 3 with staged free flap transfer) due to thrombosis of the interpositional vein grafts and
the av-loops respectively. There was one complete flap loss in the staged group.
Conclusion:
When facing a desperate local vascular situation, temporary av-Loops may supply sufficient recipient vessels for free soft tissue transfer. Thus, microsurgical
reconstruction may be performed safely also in cases with extensive soft tissue damage and vascular compromise.
Second Toe Extensor Digitorum Brevis Provides a Simultaneous Abductorplasty to Free Vascularized Metatarsophalangeal Joint
Transfer for Thumb Composite Metacarpophalangeal Joint Defect
Institution where the work was prepared: Chang Gung Memorial Hospital, Taoyuan county, Taiwan
Chih-Hung Lin, MD; Chang Gung Memorial Hospital, Chang Gung University
Background:
For functional reconstruction of a thumb metacarpophalangeal joint defect with loss of opposition, we need to address both joint mobility and thumb opposition. Free vascularized second toe joint transplantation provides joint replacement, as well as extensor and flexor tendons for apprehensile thumb restoration.
Furthermore, the extensor digitorum brevis (EDB) allows a simultaneous abductorplasty for the reconstruction of traumatized abductor pollicis brevis.
Seven patients underwent one-stage vascularized second toe metatarsophalangeal joint transfers (MTJ) to thumb metacarpophalangeal joints (MPJ) with the
aim of reconstructing post-traumatic composite soft tissue, joints, and extrinsics and/or intrinsics tendon loss. The EDB was used for restoring abduction function, with the method of repairing to either remaining abductor pollicis brevis, or palmaris longus tendon.
Results:
All 7 toe joints survived. Tenolysis and web space contracture release was performed in 3 patients. One patient underwent corrective osteotomy for radial deviation. Patients were followed up for an average of 47 months. The average active arc of motion of the joints was 27.10 (range 0 to 400). Angle of first ray
separation or circumduction presented 63.3% or 55.3% compared to the uninjured side. Opposition of the thumb was assessed with the scoring system
described by Kapandji, and the average score was 6.85.
Conclusion:
Simultaneous 2nd toe EDB abductorplasty and vascularized 2nd toe MTJ transfer can provide a one-stage thumb MPJ composite defect reconstruction with
apprehensile function.
134
Subtotal Thigh Flap and Bioprosthetic Mesh Reconstruction of Large, Composite Abdominal Wall Defects
Institution where the work was prepared: M.D. Anderson Cancer Center, Houston, TX, USA
Samuel Lin; Lawrence Gottlieb; Charles Butler; M.D. Anderson Cancer Center
Background and Purpose:
Full-thickness, composite defects of the abdominal wall are difficult to repair, particularly if locoregional tissue is insufficient for cutaneous coverage. Transposition of wellvascularized flap tissue with or without implantable mesh is often required for reconstruction. However, such factors as bacterial contamination, previous irradiation, multiple prior surgeries, and/or a chronic open wound increase the risk of mesh-related and wound healing complications. Nearly the entire skin of the thigh can be transferred as a chimeric free or pedicle subtotal thigh flap based on the lateral femoral circumflex pedicle. Bioprosthetic mesh has been shown to have good outcomes and
low complication rates when used in contaminated and irradiated wounds. We describe the combination of subtotal thigh flaps and bioprosthetic mesh for repair of large,
composite abdominal wall defects in cancer patients.
Methods:
We retrospectively reviewed patients who underwent repair of large, complex composite abdominal wall defects with bioprosthetic mesh and free or pedicled subtotal
thigh flaps at 2 institutions from 2004 to 2007. Patient, reconstruction, complication, and follow-up outcome data were obtained from a prospectively maintained database.
Results:
Six patients who received 7 subtotal thigh flaps (4 pedicled and 3 free flaps with vein grafts to the femoral vessels) met the study criteria. Indications for reconstruction
were sarcoma resection (n=2), enterocutaneous fistula (n=3), and abdominal wall osteoradionecrosis with exposed/infected polypropylene mesh (n=1). All patients except
for one received preoperative radiation therapy (mean dose 57.5 Gy). The mean musculofascial defect size was 489 cm2 (range, 300-1015 cm2) and all were repaired
with 2-mm-thick human acellular dermal matrix. The mean subtotal thigh flap skin paddle size was 527 cm2 (range, 429-720 cm2) and all donor site wounds received
a STSG. Complications included partial flap necrosis (<2% of flap area) in 1 patient, requiring debridement and flap readvancement; and partial STSG loss in 2 patients
(4 and 7% graft area), both healed with dressing changes. No bioprosthetic mesh infections, wound dehiscences, bowel obstructions, seromas, or hernias had occurred
in any patient at last follow-up (mean, 10 months).
Conclusions:
Massive, complex, composite abdominal wall defects can be successfully repaired with relatively minor complications using a combination of bioprosthetic mesh and subtotal thigh flaps. Several technical details related to flap design and harvest, bioprosthetic and flap inset, and postoperative management were identified to reduce donor
and recipient site complications and improve functional outcomes.
Preoperative Vascular Evaluation Using Computed Tomographic Angiography (CTA)
for Reconstruction of Lower Extremity Traumatic Defects with Free Tissue Transfer
Ahmet Duymaz, MD; Furkan Karabekmez; Samir Mardini; Steven L. Moran; Mayo Clinic
Objective:
Post-traumatic microsurgical lower extremity reconstruction can be complicated by damage to recipient arteries within the lower leg. CT angiography can be used as a
means of assessing lower leg vasculature in post-traumatic patients prior to undergoing free tissue transfer for lower extremity salvage. CTA avoids many of the complications associated with classic angiography, but its reliability within a trauma setting has not been prospectively evaluated. The aim of this prospective study was to examine the findings of preoperative CTA and correlate these findings to flap survival and limb salvage.
Methods:
Sixty-five consecutive lower extremity trauma patients underwent pre-operative CTA prior to free flap reconstructions. Angiography was used to assess arterial inflow,
venous outflow, and the incidence of atherosclerotic disease, traumatic occlusion or stenosis. The donor vessel for reconstruction was determined based on CTA findings
in addition to relationship to defect location. Patients were assessed for changes in renal function and any anaphylactic reactions to contrast agent following CTA. Flap
survival rates, limb salvage and post-operative complications were noted.
Results:
There were no complications associated with the CTA procedure. CTA demonstrated normal vascular anatomy in 35 patients (53.8%), anatomical variants in 6 (9.2 %),
and atherosclerotic occlusive disease in 6 patients (9.2 %). Traumatic arterial occlusion was identified in 17 patients (26.1%). One patient had a DVT of the posterior tibial (PT) vein. The anterior tibial (AT) artery was most commonly injured and occluded in 8 of 17 abnormal cases. Flap failure was seen in 6 flaps (9.2%); however limb
salvage was possible in all but 4 patients (93.8%). All 4 of the limbs amputated had at least a single artery occluded on pre-operative CTA; this was found to be significant (p<0.05).
Discussion:
The incidence of single vessel traumatic arterial occlusion within traumatized lower limbs undergoing free tissue transfer may be as high as 25%. CTA provides excellent
visualization of lower extremity vasculature following trauma. Its routine use for trauma patients is safe. Flap failure only occurred in cases of arterial compromise. Arterial
occlusion on CTA may be a risk factor for limb loss.
Expanded Perforator Free Flap Transfer
Institution where the work was prepared: University of Sao Paulo, Sao Paulo, Brazil
Fabio Busnardo, MD; Marcelo Olivan; Jose Carlos Faria; Marcus Castro Ferreira, MD, PhD; University of Sao Paulo - Brazil
The recently evolved perforator flap concepts and techniques of intramuscular dissection of the skin-feeding vessels have made flap elevation safe. Perforator free flaps
are now performed with increasing frequency for soft tissue reconstruction. In some situations, however, when a large cutaneous flap is needed, the donor site can’t be
closed primarily. Pre-expansion of a free flap can maximize available tissue for transfer and assist with closure of the donor defect. To the best of our knowledge, previous tissue expansion of perforator flaps has not been used before. We present our experience using pre-expanded thoracodorsal artery perforator flaps as a method for
reconstructing large soft tissue defects with primary donor site closure.
Between 2007 and 2008, 8 patients with large soft tissue defects were treated with expanded TAP flaps. Patient ages at the time of operation ranged from 10 to 42 years.
Three patients had lower extremity defects, and the other 5 presented burn scar contractures. In all patients pre-expansion of the flap was done to avoid the need for
donor site skin grafting. Rectangular tissue expanders were placed under the latissimus dorsi muscle through an incision made 2 cm laterally from the lateral margin of
the latissimus dorsi. Manipulation of the cutaneous perforators and thoracodorsal vessels was avoided during tissue expander placement. After tissue expansion, the flaps
were transferred. Using the same incision, the tissue expanders were removed. Dissections were carried out medially through the loose areolar tissue above the muscle.
After identifying the cutaneous perforator, dissection was continued through the muscle until the thoracodorsal vessels were found. The vascular pedicle was divided at the
level of the TDA. The pre-expanded perforator flaps were microsurgically transferred to donor areas.
All flaps completely survived and healed uneventfully. Primary donor site closure was possible in all patients. Two patients presented hypertrophic scarring at the donor
site.
As has been demonstrated in our series, the method of pre-expansion of the thoracodorsal artery perforator flap can be used to maximize cutaneous tissue for microsurgical
transfer. Expansion enabled us to close donor sites primarily, despite large flap width. Tissue expanders must be placed under the latissimus dorsi muscle to avoid inadvertent
injuries to cutaneous perforators or thoracodorsal vessels. Eight pre-expanded perforator flaps were successfully transferred with optimal functional and aesthetic results.
135
Limb Salvage in Patients With Advanced Peripheral Vascular Disease and
Complex Foot and Ankle Wounds: Free Flap vs. Amputation
Ivica Ducic, MD, PhD; Christopher Attinger; Nathan Menon; Georgetown University Hospital
Introduction:
Lower extremity limb salvage can be challenging task in patients with advanced peripheral vascular disease and complex foot defects. This selected group of,
often diabetic or renal failure patients present with a composite defects where local tissues are insufficient and/or conservative choices are either not an option
or have failed. Furthermore, they had one-vessel foot, often also involved with segmental atherosclerosis. We looked at the outcomes of consecutive patients
who underwent microsurgical limb salvage.
Methods:
Twenty consecutive patients between 2003-2008 who met the above criteria and underwent microsurgical limb salvage rather then the amputation were studied. Perioperative complications and outcome were recorded. All patients underwent initial debridments and had a multidisciplinary team evaluation/treatment (endocrine, renal,
infectious disease, etc). Reconstruction was performed only after cultures following serial debridments were negative. All patients had, by a single microsurgeon an endside anastomosis to an only available vessel and at least one (two, when available) vein.
Results:
There was an even distribution of gender between patients, while average age was 54. Sixteen patients received rectus, two gracilis, one latissimus and one
serratus muscle free flaps with split thickness skin grafts. Two patients required saphenous AV loop graft, while 15 were assisted with external fixator as well.
There was no peripoerative mortality, and there were no partial or total flap losses. Two patients had partial STSG loss, and one patient required return to OR
due to fall on the day of discharge that avulsed 70% of flap (no vascular compromise). After all patients have healed, two had recurrence of osteomyelitis and
underwent a below knee amputation 6 and 8 months later, respectively.
Conclusions:
Although these patients presented for a consultation after they were already considered for an amputation elsewhere, limb salvage with free flaps was an appropriate solution with 100% immediate and 90% success at 1 year follow up. A team approach is a must, as are serial debridments prior to considering reconstruction.
Technical component of microsurgical part of the case can be challenging due to calcified vessel wall, where a hardened cardiac micro needles can be useful. Despite
high success rate in this study, patients still need to be informed of possible failure and subsequent need for an amputation. Considering these findings, free flap reconstruction for patients with “single vessel” complex foot wounds for limb salvage is worthwhile, offering better chance for longer survival, otherwise compromised due
to increased cardiac demand in amputees.
Expanding the Limits of Macroreplantation: 18 hours Forearm Survival of Amputated
Extremities using Extracorporeal Perfusion with the Hear-Lung Machine in a Porcine Model
Institution where the work was prepared: Dr. Esther Vogelin, Bern, Germany
Esther Vogelin, MD, PhD; Chefarztin Handchirugie un Chirugie der peripheren Nerven Klinik fur Plastiche
Expanding the limits of macroreplantation; 18 hours forelimb survival of amputated extremities using extracorporeal perfusion with the heart-lung machine in
a porcine model
Goal:
Macroreplantations have to be performed within six hours from amputation, to avoid massive reperfusion damage and permanent loss of tissue and function.
Extracorporeal limb perfusion may prolong this replantation window. Following proof of feasibility in a pilot study, the maximal potential of this technique was
investigated in the current study.
Twelve forelimbs of six large white pigs were divided into two groups: I perfusion group, II contralateral cold ischemia group controls. In group I the axillary artery
and two axillary veins were cannulated and extracorporeal perfusion started after 6 hours of cold ischemia. Autologous blood was anticoagulated with heparin and
used for perfusion. Extracorporeal perfusion was performed for 12 hours. Multiple variables including p02, pC02, lactate, potassium, and pH were monitored by
blood gas analysis. Muscular and subcutaneous p02, lactate and temperature were measured by Lycox probes. Muscle contractility was tested by electrical stimulation. Neurostimulation was used to assess the motor response. The quality of the perfusion at intracellular level was assessed semiquantitatively by morphological analysis of muscle fiber mitochondria using electron microscopy.
Results:
Limb perfusion could be performed continuously for the entire period of 12 hours in all extremities of group I starting after six hours of cold ischemia. pH could
be maintained stable (mean 7.56). Potassium was well controlled with insulin and glucose (mean 6.7 mmol/l). Lactate levels remained high during the perfusion (mean 20.1 mmol/l) due to the lack of the liver in this extracorporeal system. p02 was continuously higher in arterial than in venous blood indicating a
functioning cellular metabolism. Muscular and subcutaneous temperature was constant after initial warming. Full muscle response to stimulation was observed
following a warm-up period of 40 minutes and was reproducible throughout the entire perfusion duration in all extremities after six hours of cold ischemia. In
contrast we found a complete loss of muscle response to stimulation after 20 minutes of cold ischemia in the control group. The ultrastructural analysis paralleled the significant differences between the perfused and the non-perfused extremities.
Conclusions:
The extracorporeal perfusion of amputated extremities demonstrated stable tissue effects at macroscopical, biochemical and histological level. This ex-vivo system successfully maximized the potential replantation period of amputated extremities to 18 hours. The in-vivo effects are currently under investigation.
136
ASRM - Outcome Studies
Free Flap Breast Reconstruction in Advanced Age: Is it Safe?
Institution where the work was prepared: Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA, USA
Jesse Creed Selber, MD, MPH; Meredith Bergey; Seema Sonnad; Joseph Serletti; University of Pennsylvania
Background:
Because of concern over co-morbidities and surgical risk, patients of advanced age may not be offered free flap breast reconstruction. The purpose of this study is to
determine if complications following free flap breast reconstruction are higher in older patients than in the general population.
A retrospective review of 1031 MS fTRAMs, DIEPs and SIEAs by a single surgeon over 15 years was performed. There were 976 patients <65 years of age
and 55 patients 65 years and older. Population variables included length of follow up, ASA status, BMI, past medical history including hypertension, diabetes,
peripheral vascular disease, heart disease, chronic obstructive pulmonary disease, preoperative and post-operative chemotherapy and radiation therapy, and
smoking history. Operative variables included timing of reconstruction, recipient vessels, anastamotic technique, blood transfusion, and use of heparin. Outcome
variables included length of stay, medical complications, and surgical complications including abdominal hernia, fat necrosis, partial and total flap loss, vessel
thrombosis, hematoma and seroma, mastectomy flap loss and wound infection. All analyses were repeated separately for the MS fTRAMs, DIEPs and SIEAs to
determine if outcomes differ by age. Statistical analysis included Chi-Squared, Fisher’s Exact, Mann-Whitney, and Kruskal-Wallis tests for significance.
Results:
The mean age was 47 years (24-79). For population variables, there was no difference in length of follow up, history of smoking, diabetes, peripheral vascular disease, heart disease or COPD between the <65 and 65 and over groups. The older group had a higher ASA status (2.1 v 1.9, p=0.05), prevalence of
hypertension (40% v 19%, p < 0.001), a higher average BMI (31 v 28, p = 0.046), and lower rates of pre-operative (26% v. 4%, p = 0.001) and post-operative (16% v 2%) chemotherapy. In terms of operative variables, the older group received more intra-operative blood transfusions (8% v 2%, p = 0.023) and
the coupler was used less often (10% v 29%, p = 0.004). For outcome variables, there was no difference in length of stay (3.5 days), medical complications
(4%), or surgical complications (32%), take-backs or post-operative revisions. When analyzed separately for the fTRAM, DIEP and SIEA, results were similar.
Conclusions:
In spite of higher ASA status, rates of hypertension, average BMIs, and rates blood transfusions, the 65 and older group had outcomes equal to the general population. Thus, free flap breast reconstruction in patients of advanced age is safe, and should not be denied to this population.
Patient Satisfaction with Breast Reconstruction Following Nipple Sparing Mastectomy
Steven Bernard, MD; Robert Lohman, MD; Risal Djohan, MD; Cleveland Clinic
The challenge of improving breasts aesthetics following mastectomy has led to the nipple sparing mastectomy (NSM). Initially a procedure reserved for prophylactic mastectomies, it has evolved into a safe, effective, and aesthetically sound procedure. The aesthetics are made possible through the co-operative efforts
of both general and plastic surgeons. In this study, we have reviewed the results of our reconstructive efforts following NSM through a patient survey.
We sent an introductory letter to 139 consecutive NSM patients who had reconstructions from 2000-2007. In the letter we asked the patients to participate in
a survey. A follow-up questionnaire asked the patients to rate their satisfaction with their reconstruction based on a 4 point Likert scare of Excellent, Good, Fair
and Poor. We included questions on Appearance, Symmetry, Color, Position, Sensation, Arousal and Texture. We also asked the patients if they could, what
they would change and if they would repeat the NSM/reconstruction. The types of reconstruction included expander/implant 74%, TRAM 19%, DIEP 3% and
Other 4%.
Of the 139 questionnaires sent out, we received 75 responses. The patients rated their satisfaction as good or excellent in 53-80% of the categories except for
“Sensation” and “Arousal” where the majority of patients rated their results as fair or poor (60-77%). The patients said they would definitely repeat their procedure in 70% of the cases and maybe repeat the procedure in 11%. As would be expected based on the survey, when asked what they would change, most
would like to improve sensation (64%).
In conclusion, NSM combined with reconstruction offers a satisfactory outcome in the majority of patients.
137
The Effect of Using Skin Flaps and Skin Grafts for Scrotal Reconstruction on Testicular Function
Institution where the work was prepared: Afyon Kocatepe University, Afyon, Turkey
Yavuz Demir, MD1; Fatma Aktepe1; Nazli Sancaktar1; Sebahattin Kandal2; Nurten Turhan Haktanir1; (1)Afyon Kocatepe university, (2)Gazi University,
Faculty of Medicine
Purpose:
Due to its unique composition, reconstruction of scrotal skin defects is a major challenge. This study is designed to evaluate the effects of using skin grafts and
skin flaps on spermatogenesis, to find out which method should be chosen to preserve normal testicular function.
Twenty-three male Lewis rats weighing between 125 and 150 grams were used in the study. In Group 1 (n: 8) the rats were not operated and used as control
group. In Group 2 (n:8), after removing all the scrotal skin exposing testicles, the defect was repaired using island adipomusculocutaneous flap raised from the
right groin and in Group 3 (n: 7), reconstruction was achieved using full thickness skin grafts taken from right groin region. All the rats were sacrificed at 2 months
postoperatively, the testicles were removed and wet weights of testicles were measured followed by histopathological evaluation for testicular function. The mean
diameter of the seminiferous tubules and the mean height of the germinal epithelium were measured. Spermatogenesis was determined by the semiquantitative
‘testicular biopsy score count’ (Johnsen score).
Results:
The mean wet weights of testicles were 2.83 grs, 2.63 grs, and 2.06 grs in groups 1, 2 and 3 respectively. Wet weight of testicles in control group was significantly higher compared to graft group (p=0.01). Mean height of germinal epithelium were 56.19 µm, 54.15 µm, 36.47 µm in groups 1, 2 and 3 respectively. Germinal
epithelium height was significantly more in control group compared to group 3 (grafted rats) (p=0.015). In rats treated with flaps, this value was also significantly
higher compared to grafted rats (p=0.021). Mean diameter of seminiferous tubules were 258.30 µm, 234.04 µm, and 225.43 µm in groups 1, 2 and 3 respectively. Johnson score for spermatogenesis were 7.5, 6.3, and 5.4 in groups 1, 2, and 3 respectively. In control group the score was higher compared to rats treated with flaps (p=0.004) and grafts (p=0.005).
Conclusion:
Skin grafts may maintain temperature difference for normal testicular functions, but have the disadvantage of testicular distortion and provides insensible skin
coverage. Skin flaps provides adequate coverage however, as temperature will be high in the deeper planes, it may adversely affect spermatogenesis. In our
experimental model, we found that using flap resulted in testicular functions comparable to control group, however using grafts resulted in diminished testicular
function. Therefore we suggest that flaps should be the first choice for scrotal reconstruction.
Telemedicine in Microsurgery: Case Study and Critical Evaluation
Matthew J. Trovato, MD1; Mark S. Granick, MD2; Rudolf F. Buntic1; Gregory M. Buncke1; (1)California Pacific Medical Center, (2)UMDNJ - NJMS
Introduction:
The ability to evaluate and triage plastic and microsurgery patients using telemedicine has recently become a topic of great interest. Previous studies have been
descriptive, relatively small in size, and dealt with feasibility rather than objective evaluation of accuracy and concordance between onsite and remote wound
evaluation. To determine the accuracy of digital images as compared to bedside examination, we compared wound evaluation by onsite surgeons with viewing digital images by remote surgeons.
Methods:
Over 2 years, 43 wounds in 35 inpatients and 2 emergency room patients were photographed with a Canon A80 digital camera (resolution 4.0 megapixels). Agreements regarding wound description (edema, erythema, cellulitis, necrosis, gangrene, ischemia, and granulation) and wound management (presence of a healing problem requiring intervention, need for emergent evaluation, need for antibiotics, and need for hospitalization) were calculated among
onsite surgeons and between onsite and remote surgeons. Modalities for real-time, remote microsurgical patient management were employed and evaluated.
Results:
Agreement between onsite and remote surgeons (46% to 86% for wound description and 65% to 81% for management) generally matched agreement among
onsite surgeons (68% to 100% for description and 84% to 89% for management). Moreover, when onsite agreement was low (i.e., 68% for edema) agreement
between onsite and remote surgeons was similarly low (i.e., 57% for edema). Remote evaluation was least sensitive in detecting wound drainage (46%).
Regarding management decisions, remote surgeons tended to overtreat wounds; more often prescribing IV antibiotics and admitting the patient. In one case,
the postoperative course of a latissimus dorsi microvascular transplant reconstruction of a lower lip was effectively managed remotely using digital images sent
via electronic mail. Cases in which patient transfer decisions were made and postoperative surgical site monitoring was performed via electronic transfer of
digital images and implantable doppler telemetry are also presented.
Conclusions:
Digital wound evaluation is comparable with standard examination, rendering similar diagnoses and treatment plans in the majority of cases. Though remote
evaluation cannot replace bedside examination, it may assist the microsurgeon and ER physician in triage decisions, thereby decreasing ER throughput time
and frequency of office visits, supplementing consultation to remote satellite facilities by microsurgeons, and providing real-time postoperative assessments, ultimately improving quality and reducing healthcare costs.
138
Pulmonary Complications and Upper Respiratory Tract Bacterial Flora Alteration
Following Free Ileocolon Transfer for Esophageal and Voice Reconstruction
Institution where the work was prepared: E-Da Hospital / I-Shou University, Kaohsiung County, Taiwan
Antonio Rampazzo1; Bahar Bassiri Gharb1; Christopher J. Salgado, MD2; Samir Mardini, MD3; Stefano Spanio di Spilimbergo1; Hung-Chi Chen, MD, FACS1; (1)Eda/I-I Shou University Hospital, (2)University Hospitals Cleveland / Case Western Reserve University, (3)Mayo clinic Rochester
Background:
Free ileocolon transfer has become an effective technique for the reconstruction of pharyngo-laryngectomy defects. A biological tracheoesophageal fistula for voice restoration is created using an intestinal flap characterized by resident aerobic and anaerobic flora. Regional bacterial flora modifications after flap inset and possible respiratory tract complications have not been studied.
A retrospective analysis was conducted in 34 patients who underwent reconstruction with free ileocolon flaps between April 2004 and May 2008 to evaluate respiratory and pulmonary complications. The incidence of cough, productive sputum, fever related to pulmonary infections and upper and lower respiratory tract infections were
investigated. A prospective study was conducted utilizing bacteriologic culture of the trachea-voice tube junction to assess for the presence of aerobic and anaerobic bacteria in 8 of the patients.
Results:
A persistent, pre-existing cough was present in 44.1% of patients, sputum in 47%, and fever caused by pulmonary infections was found in four patients (12%). Eight
patients (24%) early in the series experienced leakage of alimentary contents into the trachea, seven due to incompetence of the ileocecal valve and one due to pathologic tracheoesophageal fistula. Six of the patients required surgical intervention (1) flap shortening, (4) valve plication, and (1) closure of the pathologic tracheoesophageal
fistula. Five others (15%) experienced upper or lower pulmonary infections all which were successfully managed with medical therapy. The microbiologic evaluation of the
voice tube-trachea junction evidenced a rich bacterial flora usually not present in the trachea in seven out of 8 patients evaluated. E. Coli, M. Morganii, S. Marcescens,
P. Vulgaris, P. Mirabilis, P. Rustigianii, S. group B and Yeast-like organisms grew in the aerobic medium. P. Micros was the only species cultured in anaerobic conditions.
Conclusions:
Leakage of the previous alimentary tube conduit used to create the voice tube into the trachea presents a possible but acceptable risk of pulmonary infection. Treatment
of pulmonary infections in this group of patients should entail wide spectrum antimicrobial therapy while awaiting more specific results of tracheobronchial cultures.
Augmentation of Surgical Angiogenesis in Vascularized Bone Allotransplants with Host-Derived
AV Bundle Implantation, Fibroblast Growth Factor-2 and Vascular Endothelial Growth Factor Administration
Mikko Larsen, MD; Wouter F. Willems; Patricia F. Friedrich; Allen T. Bishop; Mayo Clinic
Aim:
Large skeletal defects resulting from tumors, infection or failed arthroplasty present a reconstructive challenge. Structural allografts are prone to nonunion and late stress
fracture. Vascularized autografts heal and remodel with stress, but are frequently of insufficient size and strength. Prosthetic replacement of diaphyseal bone may fail,
loosen or produce periprosthetic fractures. Transplantation of living allogenic bone would provide a replacement closely matched to the biomechanical properties of resected bone. Vascularized bone allotransplantation without the health risks of immunosuppression or tolerance induction would be an important advance. We have described
a novel method by which this is accomplished: microsurgical bone transfer with development of a new host-derived osseous blood supply. Immunosuppression needs only
to allow sufficient time for angiogenesis to occur. In the current study we aim to augment the amount of angiogenesis such that physiologic rates of bone remodeling and
blood flow are achieved.
Methods:
43 PVG rats were randomly allocated to one of four groups (see table). Each rat underwent microsurgical femoral allotransplantation from DA donors. The pedicle was
anastomosed to the femoral vessels and the contralateral saphenous artery and vein were implanted longitudinally through the medullary canal. Poly(D,L-lactide-co-glycolide) microspheres loaded with basic fibroblast growth factor (bFGF) and/or vascular endothelial growth factor (VEGF) (10mcg/graft) were imbedded in collagen-I
solution and inserted into the medullary canal. FK-506 was administered daily for 14 days. At 28 days, bone blood flow was measured using hydrogen washout. Capillary
density was measured on optically cleared grafts and histologic and histomorphometric analysis was performed.
Experimental design:
Group
Factor
1
-
Number
11
2
bFGF
10
3
VEGF
11
4
bFGF+VEGF
11
Results:
Capillary density measurements were significantly greater in group 4 (35.1%) than group 1 (13.9%) (Tukey’s multiple comparison test, p<0.05) and a significant linear
trend was found between all groups (p<0.005) (see figure). Bone formation rates were significantly greater in groups 3 (p<0.01) and 4 (p<0.05) than in group 1 (Dunn’s
multiple comparison test). Treatment with VEGF increased bone blood flow significantly more than when combined with bFGF. No difference in blood flow was found
between either growth factor alone. Histologic grades of inflammation and osteocyte viability were similar across all groups.
Conclusion:
Local administration of vascular and fibroblast growth factors specifically augments angiogenesis, bone formation and bone blood flow from implanted blood vessels of
donor origin in a vascularized bone allograft after removal of immunosuppression.
139
The Influence of Infonomic and Sociodemographic Factors on Shared Decision
Making in Microsurgical Breast Reconstruction
Institution where the work was prepared: Beth Israel Deconess Medical Center, Harvard medical School, Boston, MA, USA
Janet H. Yueh, BA; Evan Matros, MD; Eran D. Bar-Meir, MD; Theodore T. Nyame, BA; Adam M. Tobias, MD; Bernard T. Lee, MD; Beth Israel Deaconess Medical
Center, Harvard Medical School
Factors regarding the decision making process to proceed with microsurgical breast reconstruction are unknown. Sociodemographic data of patients who undergo free
tissue transfer for breast reconstruction have not been previously published. We hypothesized that patients who undergo microsurgical breast reconstruction have a unique
sociodemographic profile and access to medical care that influences the type of breast reconstruction chosen.
Women were identified who underwent either immediate or delayed breast reconstruction at a single major university hospital from January 2004-2007. Three hundred
thirty-two patients met inclusion criteria and received a mailed survey of demographic information, referral patterns, learning aids and decision making processes.
Reconstruction types offered included implant-based, latissimus, TRAM, DIEP, SIEA, and SGAP flaps. For statistical analysis, women were categorized into either microsurgical or non-microsurgical reconstructions.
A total of 255 women responded to the survey for a response rate of 76.8%. There were 47 implant, 43 latissimus, 35 TRAM, 115 DIEP, 5 SIEA, and 9 SGAP patients included in the analysis with an equal response rate between microsurgical and non-microsurgical groups. There was no significant difference in sociodemographic factors such as
race, education, employment, income, and insurance status between groups. Patients at the extremes of the age were more likely to get non-microsurgical breast reconstruction
(p=0.042). Microsurgical patients were more likely to be overweight or obese, whereas non-microsurgical patients were underweight or average weight (p=0.003). Analysis of
modalities used to learn about breast reconstruction demonstrated that microsurgical patients were more likely to use the internet (p<0.001) while non-microsurgical patients
received information from surgical oncologists (p<0.001). Consequently, microsurgical patients self referred to a plastic surgeon (p<0.001), while non-microsurgical patients were
referred by a breast surgeon (p<0.001). Patients who chose microsurgery were offered more reconstructive options by their plastic surgeon than those who underwent other techniques. Both reconstructive groups were equally satisfied with the amount of information provided by their plastic surgeon (p=0.294). Microsurgery patients reported greater
involvement in the decision making process for their procedure than non-microsurgical counterparts (p<0.001)
The referral process and decision to proceed with microsurgical breast reconstruction is complex and based on many factors. Patients undergoing microsurgical reconstruction have a similar sociodemographic background to other reconstructive procedures. Microsurgery patients are more likely to have a unique referral pattern and
learn about their procedure using non-traditional resources such as the internet. Furthermore, these women are offered more reconstructive options and play an active
role in the decision making process.
Is Microsurgical Hepatic Artery Repair Worthwhile in Pediatric Liver Transplantation?
Institution where the work was prepared: The Hospital for Sick Children, Toronto, Canada
Andre Panossian, MD1; Ronald M. Zuker, MD, FRCS(C), FAC2; Ivan Diamond, MD3; A. Fecteau, MD3; D. Grant, MD3; (1)Childrens Hospital Los Angeles, (2)Hospital
for Sick Children, (3)The Hospital for Sick Children
Background:
Early experience with Live Donor Liver Transplantation (LDLT) was complicated by the development of hepatic artery thrombosis (HAT), a devastating complication resulting in
graft-loss. Consequently, a microvascular approach to the hepatic artery has been widely adopted. We report our experience with this technique and detail the outcomes.
Method:
Retrospective review of children at our institution undergoing LDLT between March 2000 and August 2007 with the hepatic artery anastomosis performed a single
microvascular surgeon. The transplant surgeons performed the remainder of the operation. The arterial anastomosis was performed after the hepatic venous and portal
venous anastomoses; but before biliary reconstruction. All patients received anti-platelet therapy post-transplant, and doppler ultrasound is routinely performed to demonstrate hepatic artery patency. Demographics, vascular anatomy and hepatic arterial anastomotic configurations were recorded. Patient outcomes were evaluated, including 1-year arterial and biliary complications, as well as overall survival.
Results:
The median age of the 35 patients in this study was 15 (range: 4 - 204) months, and the majority (54%) of transplants were for biliary atresia. Graft type was left-lateral segment in 25, left-lobe in 3, and right lobe in 7. All arterial anastomoses were end to end, and the hepatic artery caliber ranged from 1.2 to 3 mm. Two hepatic arterial anastomoses were performed in 8 patients. There was one revision at the time of transplant in a patient with a substantial size mismatch. One patient was re-transplanted for HAT, which was associated with both portal and hepatic vein thrombosis. This patient was subsequently diagnosed with a thrombophillia. There were no other
retransplantations. Biliary complications occurred in 7 patients – leak 2, cholangitis 2, non-specific dilatation 1, stricture 2. The median post-transplant follow-up was 39
(range: 0-90) months. 1 and 6 year patient survival was 94% and 81% respectively.
Conclusion:
The results of LDLT at our institution are excellent, with patient survival in line with results at other large centers. These results are the consequence of medical and surgical advances
in transplantation including miscrovascular anastomosis in LDLT, which has lead to liver transplantation becoming standard and effective therapy for children with end-stage liver
disease. We had one case of HAT, although the patient had an undiagnosed thrombophillia so it is unlikely that technical issues were the cause of this. Biliary strictures may be
related to arterial insufficiency or due to technical issues. There were 2 such events, both of which resolved with stenting without long-term consequences.
Outcomes of Soft Tissue Reconstruction after Sarcoma Tumor Resection in Children
Institution where the work was prepared: The Hospital fo Sick Children, Toronto, Canada
T.K.S. Cypel, MD1; B. Meilik1; W. Cole1; A. Weiss-Meilik2; R.M. Zuker1; (1)University of Toronto/ The Hospital for Sick Children, (2)Sheba Medical Center
Background:
Soft tissue sarcomas are relatively uncommon cancers. They account for less than 1 % of all new cancer cases each year. However, soft tissue reconstruction after sarcoma tumor
resection in the pediatric population is increasingly challenging, aiming to improve function and form and allowing for good quality of life.
The Hospital for Sick Children records were retrospectively searched for all cases of soft tissue reconstruction after sarcoma tumor resection performed between 1995 and 2007.
Were included patients up to 18 years old of age. Tumor characteristics, oncologic treatment, ablative and reconstructive surgical procedure, and clinical and functional outcome
were reviewed. Data was analyzed using descriptive and parametric statistical methods.
Results:
We identified 69 patients who underwent surgical treatment. Of these patients 55.1% were males. The most frequent diagnosis were Osteosarcoma in 53.6%, Ewing’s
Sarcoma in 21.7%, Synovial Sarcoma in 6.2%, Dermatofibrosarcoma in 7.2% and other tumors in 11.3%.
The most common sites were thigh, hip and buttock area (56.9%), below the knee (27.5%), arm (12.7%) and chest wall (2.9%).
Preoperative chemotherapy was done in 85% of the patients. Preoperative bone marrow transplantation was performed in 3.5%.
Soft tissue and bone were involved in 74.6% of patients and only soft tissue in 25.4%.
Free fibular transplant was the procedure of choice for reconstruction in 13%. Primary closure and/or local flaps were used for soft tissue cover and reconstruction in
85.7% of cases, distal flaps in 7% and free flaps in 13%. Skin grafts were added in 11.4%
Bypass for vascular reconstruction was done in 3 patients, nerve reconstruction was necessary in 4 patients and tendon reconstruction in 3 patients. Postoperative complications included wound infection or dehiscence occurred in 2 patients and allograft fracture in 5 patients. Return to normal activities was achieved in 71.3% of cases.
Conclusions:
Carefully planned reconstructions, using advanced surgical techniques and all components of reconstruction such as primary closure, regional flaps, muscle flaps, free tissue transfer, and giving attention for all aspects of soft tissue reconstruction can determine a good and long lasting rehabilitation in children.
140
Chimerism, Malignancy, and Prolonged Graft Survival of Composite Facial Allografts in Non-Human Primates
Institution where the work was prepared: University of Maryland School of Medicine, Baltimore, MD, USA
Arthur J. Nam, MD; Matthew G. Stanwix, MD; Eduardo D. Rodriguez, MD, DDS; Steven Shipley, DVM; Stephen T. Bartlett, MD; Rolf N. Barth, MD; University of
Maryland School of Medicine
Introduction:
Composite tissue allografts may contain vascularized bone marrow of significantly different volumes. While evidence exists to support chimerism as a strategy to achieve
tolerance, the effect of co-transplanted vascularized bone marrow on graft survival and complications in composite tissue allotransplantation (CTA) has not been defined.
We have developed non-human primate models of facial and fibula CTA to investigate preclinical outcomes.
Methods:
Heterotopic facial (n=10) or fibula (n=3) CTA was performed between mismatched cynomolgus monkeys. Recipients were treated with 28 days of intravenous tacrolimus
converted to either chronic intramuscular tacrolimus (n=9), oral rapamycin (n=3), or combined tacrolimus/mycophenolate mofetil (MMF) therapy (n=1). Grafts were
inspected daily, biopsied at regular intervals, and recipients monitored for evidence of macrochimerism by flow cytometry. Endpoints included allograft rejection, compromised animal health, or development of malignant complications.
Results:
Facial CTA recipients on tacrolimus monotherapy (n=6, mean tacrolimus level = 45 ng/mL) demonstrated prolonged rejection-free graft survival (mean 116 days) with
development of post-transplant lymphoproliferative disorders (PTLD) in all long-term surviving animals. Genotypic analysis demonstrated PTLD tumors were of donor origin in 60%. One facial CTA animal receiving a blood transfusion rejected the allograft without evidence of PTLD (99 days). Fibula CTA animals (n=3, mean tacrolimus
level = 51 ng/mL) did not demonstrate any evidence of PTLD tumors, but demonstrated early skin loss but radiologic evidence of bone union suggesting viability (mean
114 days). 3 facial CTA recipients converted to oral rapamycin developed early rejection episodes and graft loss (mean 81 days). Facial CTAs contained 8 x 108 bone
marrow cells compared to 0.3 x 108 bone marrow cells in fibula CTAs. Techniques for detection of chimerism allowed testing of 4 animals. Chimerism was not detected
in fibula CTA (n=1) or facial CTA (n=2) with either early skin loss or rejection; however, ongoing chimerism was detected up to 10 weeks in one facial CTA recipient with
rejection-ffree graft survival on tacrolimus/MMF therapy.
Conclusions:
Facial composite allografts containing large volumes of bone marrow demonstrated prolonged rejection-free graft survival, with development of predominantly donorderived PTLD tumors. Persistant chimerism was detected in one animal with prolonged rejection-free graft survival. Fibula composite allografts with little bone marrow
demonstrated early skin loss, but no evidence of PTLD tumors despite similar tacrolimus levels. Co-transplanted vascularized bone marrow may support prolonged rejection-free graft survival and chimerism with a concomitant risk of PTLD development.
Methods of Free Flap Monitoring in a Non-Specialized Unit
Robert Lohman; Risal Djohan; Claude-Jean Langevin; Steven Bernard; Daniel Alam; Maria Siemionow; Cleveland Clinic Foundation
Introduction:
Flap monitoring is an important aspect of post-operative care. However, monitoring in non-specialized nursing units can be difficult. We compared different methods of
free flap monitoring: clinical and hand held surface doppler examination by the routine nursing staff, implantable doppler, and transcutaneous oximetry.
We analyzed consecutive patients undergoing free tissue transfer between January 2006 and February 2007 at a single hospital. Patients who had flaps with external
skin paddles were included. Patient demographics and operative details were recorded. Each patient underwent continuous monitoring with both arterial and venous
implantable dopplers (Cook Vascular Inc, Leechburg PA), continuous near infra-red spectroscopy tissue oximetry (Vioptix Inc, Fremont CA) as well as intermittent hourly
monitoring with a hand held surface doppler and clinical examination by the nursing staff. A change in the internal or external doppler signal characteristics, a reduction of tissue oxygen levels by 30%, or a change in the clinical appearance of the flap (color, capillary refill, temperature or swelling) were considered evidence of potential vascular compromise and reason to return to the operating room for exploration of the microvascular anastomosis.
Results:
Thirty-eight patients with a mean age of 39 years were studied. There were 18 DIEP flaps, 15 ALT flaps and 5 TRAM free flaps. Five developed evidence of vascular compromise and were explored: there was 1 partially occluded artery, one totally occluded artery, 1 partially occluded vein and 2 totally occluded veins. All 5 flaps with vascular compromise were initially identified by a reduction in tissue oxygenation. There were no false positives and no false negatives with oximetry monitoring. Two patients
developed clinical signs of venous congestion (brisk capillary refill and darkened color) one hour after the change in tissue oxygenation was noted. One of 2 patients with
arterial compromise, and 2 of 3 patients with venous compromise were identified by a change in the internal doppler signal one hour after they were initially identified
by oximetry changes. All of the compromised anastomoses were successfully revised and all of the flaps survived.
Conclusion:
In our patients, who are not admitted to a dedicated flap unit, near infra-red spectroscopy oximetry allowed for accurate, quantitative monitoring by the nursing staff. The internal doppler was also an accurate method of flap monitoring. However, tissue oximetry identified flaps with vascular compromise 1 hour earlier that the internal doppler. External
doppler and clinical examination were less useful methods of flap monitoring.
Disparate Outcomes for African American Women Following Autologous Breast
Reconstruction: Seven Year Evaluation of 17,436 Patients from the Nationwide Inpatient Sample
Institution where the work was prepared: Johns Hopkins University School of Medicine, Baltimore, MD, USA
Brendan J. Collins, MD; David C. Chang, PhD; Gedge D. Rosson, MD; Johns Hopkins Medical Institutions
Purpose:
Patient race is a well-documented predictor of a woman’s choice of breast reconstruction. However, one would predict that the patient’s race would not affect the complication rates from surgery once a patient has chosen autologous tissue reconstruction. Thus, we sought to examine racial differences in clinical outcomes for women undergoing autologous breast reconstruction.
Methods:
The study population included a nationwide sample of female patients undergoing autologous breast reconstruction from 1998 through 2004. Discharge data from the
Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) were analyzed for female patients over 18 years of age with ICD9 procedure codes for
autologous breast reconstruction (85.7 or 85.85, which are codes for breast reconstruction with either a free flap, a latissimus flap, or a unilateral or bilateral TRAM flap).
We examined patient variables including age, race, and Charlson score (co-morbidity index), and treatment variables including hospital volume for the procedure and
hospital teaching status. Bivariate and multivariate analyses assessed outcomes including death, thromboembolic complications, transfusion rate, length of stay, and overall hospital charges (adjusted by inflation to reflect 2006 dollars).
Results:
A total of 17,436 patients were identified. 80 percent of the study population was Caucasian (n=14,110), with 9 percent being African American (n=1,538). Bivariate
analyses demonstrated that African American women undergoing autologous breast reconstruction had significantly greater preoperative co-morbidities, greater lengths
of stay (4.4 days vs 3.9 days, p<0.001), total hospital charges ($28,852 vs $26,861, p=0.003), transfusion rates (12.9% vs 7.0%, p<0.001), and overall risk of inpatient hospital death (0.20% vs 0.03%, p=0.003) following autologous breast reconstruction. On multivariate analyses, which corrects for the greater co-morbidity score,
African American race was significantly associated with death (OR 8.8, p=0.009), transfusion (OR 1.86, p<0.001), greater length of stay (+0.50 days, p<0.001), and
total hospital charges (+$2864, p<0.001).
Conclusions:
These data demonstrate significant differences in outcomes for Caucasian and African American women undergoing autologous breast reconstruction, even after adjusting for patient co-morbidities. It is unclear why racial disparity would exist for a generally low-risk, elective procedure. Prospective public health measures should be developed and implemented to address these disparities. The busy breast reconstructive microsurgeon must be aware of these risks in order to appropriately counsel his or her
African American patients.
141
ASRM - Research: II
Retrograde Internal Mammary Venous Anastomosis To Augment Outflow In DIEP Flap Breast Reconstruction
Institution where the work was prepared: University of Utah, Salt Lake City, UT, USA
Mahlon Alder Kerr-Valentic, MD; Jayant P. Agarwal, MD; University of Utah
Background:
The deep inferior epigastric perforator flap (DIEP) has become an increasingly popular option for post-mastectomy reconstruction. These flaps may have a greater
incidence of venous congestion and fat necrosis, and several methods have been described to improve venous outflow. Salvage techniques such as venous supercharging and interconnection of the superficial and deep venous systems have been described by other authors. The concept of retrograde venous drainage has
been described previously in reverse radial forearm flaps, but its use with DIEP flaps for breast reconstruction is limited. We present a new option for augmenting venous outflow in DIEP breast reconstruction by creating an anastomosis between a vena comitante of the deep inferior epigastric artery with the retrograde
venous limb of the internal mammary vein (IMV).
Methods:
A series of fifteen DIEP flaps were prepared by anastomosing the deep inferior epigastric artery with the internal mammary artery and one vena comitante
with the antegrade IMV. An additional venous anastomosis was then made between the second vena comitante and the remaining IMV in a retrograde direction. Venous congestion was assessed before releasing the antegrade IMV anastomosis after inflow had been established and outflow was based solely only
on the retrograde system. Intraoperative duplex ultrasound was utilized to demonstrate the direction of venous blood flow away from the flap and into the retrograde IMV.
Results:
Fifteen consecutive DIEP flaps were created for breast reconstruction using the above described retrograde IMV over a three month period. After creating the
arterial and retrograde venous anastomoses and establishing flow through the flap, no evidence of venous congestion was seen. Retrograde directional blood
flow was demonstrated using intraoperative duplex imaging of the venous anastomosis with the retrograde IMV. All fifteen flaps were successful and displayed
no evidence of venous congestion.
Conclusions:
The clinical course of the retrograde augmented DIEP flaps was robust without development of venous congestion. Utilization of a venous anastomosis to the retrograde
IMV provides a large caliber vessel which should improve venous outflow when compared to an antegrade IMV anastomosis alone. The combination of this outflow with
an antegrade anastomosis should provide superior venous outflow when compared to single vein anastomoses. Intraoperative duplex ultrasound was used to confirm
these findings, and supports the use of a retrograde venous IMV anastomosis to improve DIEP flap survivability. Further long term data collection will provide information on the benefits this technique has on limiting fat necrosis.
VEGF Upregulates iNOS Expression in the Muscle Flap Ischemia Model in the Rat
Institution where the work was prepared: University of Mississippi Medical Center, Jackson, MS, USA
Barbara Persons, MD; Zeng-Gan Chen, MD; Lin Lin; William Lineaweaver, MD; Feng Zhang, MD, PhD; University of Mississippi
Introduction:
This investigation was devised to elucidate regulation of iNOS expression by VEGF in a gracilis muscle flap ischemia model in rats.
Methods:
Sixty adult male Sprague-Dawley rats were randomly divided into two groups (n=30). After 4 hours ischemia, the experimental group received intravenous
VEGF-treatment into the isolated gracilis flap pedicle and the control group received saline in the same fashion. At time intervals of 0, 2, 6, 12, and 18 hours
(n=6), tissue samples were biopsied for RT-PCR, routine HE staining and CD31 immunohistochemical staining.
Results:
The iNOS expression was reported as a fraction of growth factor to B-actin (Mean +/- standard deviation). Expression of iNOS was detected in the flaps. The
iNOS expression from normal gracilis muscle was 0.45 +/- 0.08. In the VEGF administration group, mean iNOS expression from muscle flaps was 0.26 +/0.08 while the saline injected control group was 0.54 +/- 0.11. In the experimental group, mean flap iNOS expression was 2.39 +/- 0.16, 2 hours post reperfusion which was significantly higher than the iNOS from control flaps (0.32 +/- 0.09) (p<0.01). At 6 hours of reperfusion, the iNOS expression in the VEGF
injected muscle flaps was 2.40 +/- 0.19 compared to the control 0.85 =/- 0.13. Twelve and 18 hours after reperfusion there were no significant differences in
iNOS expression between the two groups (P>0.05).
On histologic analysis, VEGF treated muscle fibers were more organized and capillaries appeared normal compared with saline injected flaps where muscle
fibers were distorted with inflammatory cell infiltration and capillary disarray. CD31 immunohistochemical staining confirmed these findings, in which all
endothelial cells were stained with anti-rat CD31 antibody and microvessels were represented by light green capillaries. In the VEGF administration group,
endothelial cells stained with the fluorescence as compared with fewer in the control group.
The iNOS expression increased rapidly over the first two hours as well as being increased over 6 hours in the gracilis muscle flap ischemia model in rats compared with
the control group (P<0.05) but with no statistically significant difference at twelve and eighteen hours between two groups (P>0.05) .
Conclusion:
VEGF has been found to improve survival of the ischemic muscle flap. In this study application of VEGF maintains the structure of capillaries and upregulates
iNOS expression in the ischemic muscle flap in a rat model. These findings may provide further evidence to study the mechanism of VEGF in improving muscle flap survival.
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Activated Protein C Improves Ischemic Flap Survival Via Angiogenic and Anti-Inflammatory Gene Modulation
Institution where the work was prepared: Dalhousie University, Halifax, NS, Canada
Michael Bezuhly, MD; Steven F. Morris, MD, MSc; Ridas Juskevicius, MD; R. William Currie, PhD; Kenneth A. West, MD; Robert S. Liwski, MD, PhD;
Dalhousie University
Background:
Flap necrosis remains a major complication in reconstructive surgery. To date, only vascular delay consistently reduces necrosis but with increased surgical morbidity. Activated protein C (APC), a natural serum anticoagulant, possesses angiogenic and cytoprotective properties. The authors evaluated whether systemic
APC can improve ischemic skin flap survival.
Methods:
A cranially based dorsal musculocutaneous flap was elevated on each rat. Forty-four animals received three intravenous injections of APC (25 mcg/kg) or
saline. Animals were divided into three experimental groups depending on the timing of the first injection: postoperative (45 minutes postoperatively, n=12
APC-treated or control animals); late preoperative (45 minutes preoperatively, n=5); and, early preoperative (3 hours preoperatively, n=5). In all groups, second and third injections were performed at 3 and 24 hours postoperatively. Flap survival was measured on day 7. Histological specimens were collected on
days 2 and 7. Real-time PCR specimens were collected at 3 and 24 hours.
Results:
Postoperative APC improved flap survival (68.9 ± 4.3 percent) compared to control treatment (39.3 ± 1.5 percent; p<0.001). Late preoperative APC treatment
produced diffuse flap hemorrhage. Early preoperative APC injection resulted in near-complete flap survival (96.1 ± 1.1 percent for APC versus 50.1 ± 3.3
percent for control; p<0.001). Histology revealed fewer inflammatory cells, improved muscle viability and increased blood vessel density in APC-treated versus control rats. APC treatment significantly reduced mRNA levels of pro-inflammatory ICAM-1 and TNF-alpha, while increasing levels of angiogenic factors
Egr-1 and VEGFR2.
Conclusions:
Systemic APC modulates genes involved in angiogenesis, inflammation and apoptosis and improves ischemic flap survival.
The Impact of Various Components of Facial Allograft on Chimerism Induction in Different Face Transplant Models
Aleksandra Klimczak, PhD; Galip Agaoglu; Ilker Yazici; Sakir Unal; Yalcin Kulahci; Maria Siemionow; Cleveland Clinic
Introduction:
In animal models, the level of chimerism and tissue distribution is variable and depends on the type of transplanted tissue. The skin is considered as the most
immunogenic tissue, and bone marrow (BM) as a permissive tissue for allograft acceptance. We present the functional outcome and long-term survival based
on chimerism induction in different facial allograft models under low-dose of CsA monotherapy.
Methods:
A total of 158 face transplants were performed. The models differed in the content of tissue components from vascularized facial skin to vascularized composite facial skin/bone allografts. Sixty-seven isografts served as controls for all tested models. Ninety-one face transplants were performed between LBN(RT1l+n)
donors and LEW(RT1l) recipients in 5 experimental models: face/scalp (n=20), hemiface (n=36), hemiface/calvaria (n=7), hemiface/mandible (n=18) and
maxilla (n=10), under low maintenance dose of CsA monotherapy. Flow cytometry assessed donor-specific chimerism for T-cells (RT1n/CD4 and RT1n/CD8)
and B-cells (RT1n/CD45RA) in the blood and BM, and immunocytochemistry tested engraftment of donor-origin cells into lymphoid organs of recipients. MLR
assay assessed responsiveness to donor antigens.
Results:
All isografts survived indefinitely. Facial allografts survival was: for face/scalp up to 225 days, hemiface to 440 days, hemiface/calvaria to 220 days, hemiface/mandible to 378 days and for maxilla up to 105 days. At 100 days post-transplant chimerism (RT1n) was represented predominantly by T-cell populations’ at 3.04% in full face versus 10.7% in hemiface recipients. In contrast, in models containing vascularized BM component chimerism was maintained by
B-cell population RT1n/CD45RA and was determined at: 6.7% in hemiface/calvaria, 4.6% in hemiface/mandible and at 4.7% in maxilla, when compared to
full face (0.6%) and hemiface (0.87%) allografts without bone components. Donor-origin cells detected in the BM compartment of face allografts ranged from
2.5% to 3.1% of RT1n. Immunocytochemistry confirmed engraftment of donor-derived cells into lymphoid organs of long-term surviving face transplants recipients. MLR assay confirmed hyporesponsiveness to donor antigens.
Conclusions:
Presence of active bone marrow cells within vascularized bone marrow compartment in the hemiface/calvaria, hemiface/mandible and maxilla allograft models facilitated migration of passenger leukocytes from the transplanted facial flaps into donor cmpartment. In these models the presence of oral mucosa, submandibular and submaxillary lymph nodes, and salivary glands, rich in hematopoietic cells could contribute to donor chimerism induction and maintenance.
This study confirmed induction of chimerism in all face allograft models, however facial flaps without bone component were chracterized predominantely by Tcell population and facial/bone allograft models by B-cell chimerism.
143
Alternative Vascular Pedicle of the Anterolateral Thigh Flap: The Oblique Branch of the Lateral Circumflex Femoral Artery
Institution where the work was prepared: Department of Plastic Surgery, Chang Gung Memorial Hospital, Tao, Taipei, Taiwan
Chin-Ho Wong, MBBS, MRCS, (Ed)1; F.C. Wei2; Brian Fu2; Ying-An Chen2; Jeng-Yee Lin2; (1)Singapore General Hospital, (2)Chang Gung Memorial Hospital
Introduction:
The anterolateral thigh flap is known for variations of its vascular pedicle. This is a prospective intra-operative analysis of the vascular anatomy of lateral thigh that focuses on clinically important variations that impacts the harvest.
Methods and Materials:
Eighty-nine consecutive anterolateral thigh flaps were harvested. A detailed intra-operative analysis was made of the vasculature anatomy and variations of the pedicle
encountered during dissection.
Results:
Fasciocutaneous flaps were harvested in 82% (73/89) and myocutaneous flap in 17% (15/89) of cases. Sizable perforators were absent in 1% (1/89) of cases. A mean
of 1.9 sizable cutaneous vessels was identified. Musculocutaneous perforators were noted in 85% of cases and septocutaneous vessel was seen in 15%. Most septocutaneous vessel was located in the proximal thigh. In the mid-point of the thigh, musculocutaneous perforators predominate. Those located within 1 cm of the septum characteristically have a short, direct intra-muscular course. In contrast, those located more laterally and distally in the thigh characteristically have a tortuous intra-muscular
course. The oblique branch of the lateral circumflex femoral artery is a variably present and previously unnamed branch located between the transverse and the descending branches of the lateral circumflex femoral artery. An oblique branch was noted to be present in 35% (31/88) of cases and the dominant perforator supplying the
anterolateral thigh was noted to originate from this branch in 14% (12/88). In these instances, anterolateral thigh perforator as well as myocutaneous flaps were harvested successfully based on the oblique branch, leaving the descendinng branch in-situ.
Conclusion:
This study further clarified the vascular pedicle anatomy of the anterolateral thigh. The existence of an oblique branch in was demonstarted in 35% of patients and used
as the flap pedicle in 14% of cases in this study. Its clinical significance should be emphasised. However with the perforator flap and free-style flap concepts, the anterolateral thigh flap can be successfully procured regardless of the course of the perforator or the source of the vascular pedicle.
Free Serratus Fascia Flap - Anatomic Study & Clinical Application
Institution where the work was prepared: University of California, San Diego, CA, USA
Lars H. Evers, MD; Dhaval Bhavsar; Mayer Tenenhaus; Richard Bodor; Gottfried Lemperle; University of California
Introduction:
Coverage of exposed functional structures in extremities requires thin, supple tissue. Various local and free flaps have been described, however excessive bulk and donor
site morbidity remains the common problem. Free Fascial Flaps have proven to be a valuable alternative. The Serratus Fascia “free flap of gliding tissue”, based on thoracodorsal vessels, includes fascial layer overlying Serratus muscle between Latissimus Dorsi und Pectoralis Major Muscle. This flap provides excellent replacement for
defects of extremities with loss of fascial layer. The aim of the study was to analyze anatomical details / clinical relevant variations in a cadaver dissection study, conduct
objective measurement of biomechanical stability and finally the clinical application of the flap.
Methods:
10 fresh cadaver trunk dissections under 3x magnification were performed. Measurement of diameter, length, number of branches, origin, topographic relation and
anatomical landmarks of long thoracic nerve, thoracodorsal artery with serratus branch, lateral thoracic artery and flap dimension was done with flexible micrometer.
The biomechanical measurement of bursting strength was performed with force gauge.
Results:
The average flap dimension after harvesting was 15 x 20 cm. The mean effective pedicle length of the thoracodorsal artery was 15.1 cm ± 3.8 cm. The diameter of the
serratus branch was 2.2 mm ± 0.6 mm, in 60 % occurred 1 serratus branch, in 30 % 2 branches and in 10 % 3. In 80 % a collateralization with lat. thoracic artery was
observed. The mean bursting strength of harvested fascia was 5.7 N, considerably higher in comparison to fat (0.7 N). The clinical application of this flap was performed
for various defects.
Conclusion:
Based on this anatomic study the Serratus fascia flap, with reliable flap dimension (larger/safer then temporoparietal fascia flap), has potential for various clinical applications beyond
coverage of hand defects. The flap is thin, supple with excellent functional and aesthetic properties. We think potential further clinical applications are extensive craniofacial defects,
defect coverage of lower extremity wounds and “wrap around flap” at axillary plexus after neurolysis in case of painful neuritis after mastectomy.
The Extended ALT Flap: Anatomical Basis and Clinical Experience
Michel Saint-Cyr, MD; Mark Schavarien, MBBS, MRCS; Corrine Wong, MBBS, MRCS; Gary Arbique, PhD; Puru Nagarkar;
Spencer Brown, PhD; Rod Rohrich, MD; UT Southwestern Medical Center, Dallas
Reports suggest that the ALT flap can be reliably extended to include adjacent vascular territories. The vascular basis of this phenomenon is poorly understood. This study examines the three- and four-dimensional arterial and venous anatomy of the extended ALT flap and reports the results of a clinical series of extended ALT flaps. Fifteen anterior
hemi-thigh specimens harvested from fresh cadavers from the Western population were used in the study. Four-dimensional CT angiography using injection of iodinated contrast medium into isolated perforators and their venae commitantes was used to investigate the arterial and venous anatomy and pattern of perfusion. Injection of perforators
and their venae commitantes within the lateral femoral circumflex femoral vascular territory, as well as those of the common femoral and superficial femoral arteries, were performed to investigate the vascular connections within the extended ALT flap. Static three-dimensional imaging and latex dissections were also performed to confirm the results.
A clinical series of 12 consecutive patients is also reported in which extended ALT flaps was used for post-trauma or post-oncological reconstruction. Large diameter linking
vessels at the suprafascial level enabled perfusion of the adjacent common femoral and superficial femoral artery vascular territories, and are preserved if the deep fascia is
raised with the flap. In the clinical series the flap cutaneous territory ranged from 250 to 630 cm2 (mean 365 cm2), with all flaps except one perfused by a single perforator.
No partial or complete flap losses occurred. This study reports the vascular basis and clinical safety of the extended ALT flap, which can be harvested if the linking vessels
between adjacent vascular territories in the anterior thigh are preserved, and reliably perfused by a single perforator.
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Three and Four - Dimensional Computer Tomography Angiographic Studies of Internal Mammary Artery Perforator Flaps
Corrine Wong, MBBS, MRCS; Michel Saint-Cyr, MD; Gary Arbique, PhD; Spencer Brown, PhD; Rod Rohrich, MD; UT Southwestern Medical Center, Dallas
The technique of three- and four-dimensional CT angiography allows us to analyze the perfusion of internal mammary artery perforators. A total of ten hemichests were harvested from five fresh cadavers. The presence, size, and location of the internal mammary perforators were recorded. The perforators were
cannulated and injected with Omnipaque contrast using a Harvard precision pump at 0.5ml/minute, and the flap subjected to dynamic CT scanning using a
GE Lightspeed sixteen slice scanner. Images were viewed using both General Electrics and TeraRecon systems, allowing analysis of perfusion flow, as well as
measurements of vascular territory and direction of flow. The flaps were also subjected to methylene blue injection studies to determine the vascular cutaneous
territory of each cannulated perforator. The first and second intercostal perforators were found to have the largest vascular territory which reached the nipple
aerola complex in all cases. On occasion, linking vessels are found between internal mammary perforators and branches of the lateral thoracic artery, thus
increasing the size of the vascular territory. This study provides the basis of pedicled internal mammary artery perforator flaps, which can be utilized in the
reconstruction of the chest, head and neck. Figure 1: Left- 3D CT angiographic study of injected first intercostal space internal mammary artery perforator in
a left hemi-chest flap Right – Photograph of the same flap, with methylene blue dye injected into the same perforator. Scalpel indicates level of the perforator.
Influencing Flap Survival Rate in a Rat Model via Pharmaceutical Preconditioning
Institution where the work was prepared: Department of Hand-, Plastic and Reconstructive Surgery, Ludwigshafen, BG Trauma Center, Germany
Holger Engel, MD1; Emre Hakki Gazyakan, MD, ;, MSc1; Natalie Desilie1; Martha Maria Gebhard, MD, ;, PhD;1; Markus Volkmar Küntscher, MD, ;,
PhD;2; Guenter Germann, MD, ;, PhD;1; (1)Ruprecht-Karls University of Heidelberg, (2)Traum Center Berlin
Introduction:
A novel strategy with pharmaceutical preconditioning plays an important role in diminishing the ischemic reperfusion injury (IRI) thus leading to an increased
overall flap survival rate. There is a significant influence of nitric oxide (NO) donors in reducing IRI via downregulation of adhesion receptors and molecules
at the expense of evident hemodynamic side effects. Endothelial, neuronal and inducible NO-Synthetases (NOS) are exogenous recombinant produced
enzymes. Most cell types and tissues possess one or more isoforms of these NOS. The aim of this study was to investigate the role of NOS in the complex mechanism and interaction of IRI improving flap survival rate with monitoring hemodynamic side effects.
Method:
We divided 64 male Wistar rats into 8 experimental groups (n=8). On each rat an extended epigastric adipo-cutaneous flap (6x10cm) based on the left superficial epigastric artery and vein was performed. Thirty minutes before a three hour flap ischemia the NOS with-/-out L-Arginine were applied through a central vein catheter. The plasma concentration of L-Arginine and L-Citrulline were measured before and after the injection. Blood pressure, heart rate and temperature were monitored. Flap survival rate was measured 5 days postoperatively with an intravital fluorescence perfusion camera and planimetry software.
Statistic was performed with f-, t- Test and an Analysis of Variances (ANOVA). A p-value ≤0, 05 was considered as significant. Experiments were approved
by the Committee on Animal Rights Protection and performed in accordance with the German legislation on the protection of animals.
Results:
In the control group without Enzymes and L-Arginine the mean survival rate was 10,5%, with L-Arginine solely 25,5%. NOS improved the survival rate significantly compared to the control group for inducible NOS 20,9% solely and 26,4% when L-Arginine was added. 20,5% and 29,4% for neuronal NOS and best
results for endothelial NOS with 30,6% and 32,4% survival rate. Hemodynamic side effects were significantly reduced.
Conclusions:
Our unpublished data shows for the first time that pharmaceutical preconditioning with nitric oxide synthetases can significantly enhance the survival rate and
reduce the ischemic reperfusion injury. With endothelial nitric oxide synthetase combined with L-Arginine best results could be achieved. Hemodynamic side
effects were significantly reduced compared to a group where nitric oxide donors were given solely.
Repopulation of Vascularized Bone Allotransplants with Recipient-Derived Cells:
Detection by Laser Capture Microdissection and Real-Time PCR
Michael Pelzer, Dr1; Mikko Larsen, MD2; Patricia F. Friedrich2; Ra Aleff2; Allen T. Bishop2; (1)University of Heidelberg, (2)Mayo Clinic
Mechanisms underlying successful composite tissue transplantation must include an analysis of transplant chimerism, which is little studied, particularly in calcified tissue. We have developed a method enabling determination of lineage of selected cells in transplant tissue sections using laser capture microdissection.
Quantitative real-time PCR of extracted DNA is performed, for a gene unique to recipient animal and a ‘housekeeper gene’ common to transplant and recipient. Subsequent analysis allows a calculation of the relative expression of each, and therefore the extent of chimerism.
We have applied this method to study our method of vascularized bone allotransplantation, using sex-mismatched transplantation of rat femora. Short-term
immunosuppression (IS) combined with simultaneous development of a recipient-derived neoangiogenic circulation. Vascularized female DA rat femoral allotransplants were performed to male PVG recipients. 4 groups differed in immunosuppression (+/- 2 week FK-506) and angiogenesis (patent or ligated AV
bundle). The Y-chromosome gene Sry and the cyclophilin ‘housekeeper’ gene were used in PCR analysis.
Results were assessed at 18 weeks. Substantial transplant chimerism was seen in cortical bone of all groups (range 77-97%), but was highest in animals with
patent AV bundles, and lowest with short term IS, which maintained transplant cell viability.
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An Innervated Eyelid Flap for Future Allotransplantation: An Anatomic Study
David W. Mathes; James Edwards; Peter C. Neligan; University of Washington
Introduction:
The future of facial reconstruction with a composite tissue allograft (CTA) will likely be based on the ability to selectively replace lost or damaged specialized
tissue such as the eyelid. While initial research examined the transplantation of the entire face, the clinical cases have replaced sub-units such as the lips and
nose. We sought to examine if the eyelid and its surrounding tissues could be harvested as a unit to be used in a future functional eyelid transplant. In addition, we hypothesized that based on the classic anatomic teaching this flap could be based on the transverse facial artery.
Methods:
12 fresh cadaver heads were used and yielded two separate flaps (N = 24). The internal carotid (ICA), facial(FA), and superficial temporal arteries(STA) were
isolated, cannulated and injected with a specific color of gelatin/dye mixture. Blue acrylic dye was injected into the FA, red acrylic dye for the STA, and green
acrylic dye for the ICA. The flap was designed to include both the TCA or the FA and the Zygomatic and Buccal branches of the facial nerve (See figure below).
In each flap we also documented the adequacy of each arterial in-flow system (Angular and Transverse facial artery).
Results:
The blue acrylic dye injected into the STA uniformly stained the skin and subcutaneous tissue of the eyelid/periorbital facial subunit, extending superiorly onto
the lower brow. There was direct perfusion of the periorbital subunit via the Transverse Facial Artery (TFA) in 60% of the flaps. In the other 40% a TFA branch
was either missing or was extremely small in size. In those cases the temporal artery sent of larger branches into the eyebrow and upper lid region and the
cadaver had a dominant Angular artery of large caliber. Injection into the Facial Artery resulted in staining of the skin and soft tissues in the medial canthal
region and superior eyelid skin in approximately 70% of specimens. In the other 30% the angular artery was not present above the lateral nasal sidewall.
Conclusions:
A composite eyelid flap can be reliably elevated utilizing either the TFA or the Angular artery based on our dye injection studies. However, we have demonstrated significant anatomic variations in both the size and presence of the transverse facial and angular arterial systems. This study demonstrates that the vascular supply an eyelid allotransplant is variable and may require dual inflow from the STA and FA systems.
146
Thoracic and Lumbar Perforators: Four-Dimensional Vascular Anatomy, Cluster
Analysis, and Implications for Pedicle Perforator Flap Designs
Kathleen Herbig, MD; Michel Saint-Cyr; Corrine Wong; Gary Arbique; Spencer A. Brown; Rod J. Rohrich; UT Southwestern
Medical Center at Dallas
Introduction:
Pedicled perforator flaps, incorporate the advantages of reduced donor site morbidity, allow the replacement of like with like, and avoid the
risks associated with microvascular anastomosis. The thoracic and lumbar regions are dense in perforator concentration and provide a large
potential for pedicle perforator flap designs.
Methods:
A total of ten fresh cadaver hemi-backs were used and all perforators ? .5mm were dissected in both the thoracic and lumbar regions.
Perforator location was measured relative to C7 and the midline for thoracic perforators and relative to the coccyx and midline for the lumbar perforators. The perforators were cannulated and injected with Omnipaque contrast using a Harvard precision pump at 0.5ml/minute,
and the flap subjected to dynamic CT scanning using a GE Lightspeed sixteen slice scanner. Images were viewed using both General Electrics
and TeraRecon systems, allowing analysis of perfusion flow, as well as measurements of vascular territory and direction of flow.
Results:
A total of 393 perforators were dissected from both the thoracic and lumbar regions. The average number of perforators in the thoracic region
was 17.8; median 15.5, mode: 15, whereas the average number of perforators in the lumbar region was 21.5; median 21.5, mode: 21.
Direction of flow is dependant on perforator location either centrally or peripherally. The lumbar perforators were the largest encountered.
Conclusion:
This study provides the basis of pedicled perforator flaps from the thoracic and lumbar regions for reconstruction of midline and lateral defects of the
back. Figure 1. Entire hemi-lumbar region harvested with a single cannulated perforator from the left lumbar region showing large vascular territory.
147
ASRM - Clinical Head & Neck I
Two Small Independent Flaps from One Radial Forearm Donor Site for
Buccal Mucosa Reconstruction after Release of Submucous Fibrosis
Chung-Kan Tsao; Fu-Chan Wei, MD, FACSn/a; Ming-Huei Cheng, MD, proffesor; Chwei-Chin Chuang, MD, proffesor; Jeng-Yee Lin, MD; Chang Gung
Memorial Hospital, Chang Gung University and Medical College
Background:
Oral submucous fibrosis is a collagen disorder affecting the submucosal layer and often severely limiting mouth opening. The use of bilateral forearm flaps to
fill the buccal defects after the trismus release has proved effective and reliable. However, this method sacrifices both radial arteries from bilateral forearms. To
eliminate the donor site morbidity, we developed a technique that allows the harvest of two independent flaps from one radial forearm donor site.
Methods:
A total of 16 flaps were elevated from 8 donor sites for post-release reconstruction of oral submucous fibrosis. Mean flap size was 6.6 x 2.6cm (range: 6 x
2.5cm to 7 x 3cm), mean pedicle length was 5.7cm, mean ischemia time was 46minutes and mean total operation time was 8 hours 45 minutes. Improvements
of mouth opening and the buccal pliancy were evaluated respectively by comparing preoperative and postoperative inter-incisor distance (IID) and maximal
mouth capacity (MMC).
Results:
All flaps survived completely, and all donor sites were closed primarily except one. At an average of 19.8 months’ follow-up, the IID averaged 29.13 mm, an
increase of 20.88 mm compared with the preoperative value. The MMC averaged 55.63 cc, an increase of 9.38 cc compared with the preoperative value.
One patient developed flap inclination between the teeth postoperatively which required extraction of all third molars. Two patients developed recipient site
abscess formation and both subsided after conservative treatment.
Conclusion:
Two independent small flaps can be harvested safely from one radial forearm donor site to reconstruct bilateral buccal defects with more insignificant donor
site morbidity. Mouth opening can be much increased and maintained by this reconstructive approach.
Monitoring Buried Fasciocutaneous Free Flaps in Pharyngoesophageal Reconstruction
Institution where the work was prepared: University of Texas MD Anderson Cancer Center, Houston, TX, USA
Robert EH Ferguson, MD; Peirong Yu, MD; University of Texas MD Anderson Cancer Center
Background:
While postoperative monitoring of microsurgical reconstruction is key to discovering early vascular compromise, monitoring a buried flap may prove problematic. Methods. A single surgeons’s tracheal and pharyngoesophageal reconstructions with fasciocutaneous free flaps between July 2002 and December 2007
were reviewed and different monitoring techniques were examined.
Results:
Eighty-six cases of pharyngoesophageal and eight cases of tracheal reconstructions were identified. The anterolateral thigh flap was used in 78 patients and
radial forearm flap in 16 patients. Monitoring techniques were categorized in three groups. In group I, a component of the flap was used for simultaneous neck
resurfacing while serving as a monitoring segment in 59 patients. No flap compromise or failure occurred. In group II, either an implantable Doppler or handheld Doppler device was used to monitor a completely buried flap in 29 patients. The implantable Doppler had a false positive rate of 31% leading to unnecessary surgical exploration and one unrecognized flap loss whereas one unrecognized flap loss occurred with the hand-held Doppler method. In group III, a
segment of tissue, skin or muscle, separate from the main flap but sharing the same source vessels was temporarily externalized for monitoring purpose only
and removed before discharge. There were no thrombosis or flap losses in this group.
Conclusion:
While external monitoring segments have been used with jejunum flaps or buoys used in other buried flaps, this external segment technique is a more novel approach
to buried fasciocutaneous flaps. The external segment is temporary and based upon a separate perforator or muscle branch sharing a common source vessel as
the tissue used for structural reconstruction. As clinical examination is a more reliable method of monitoring flap perfusion postoperatively, application of a temporary monitoring segment allows easy clinical examination to the unique scenario of buried flaps without creating unnecessary skin coverage. Once monitoring is
no longer necessary, the external tissue segment may be removed at bedside prior to discharging the patient from the hospital. Our experience with this technique
is limited to head and neck reconstruction, but this concept may be applied to other regions requiring a buried flap. It is also important to note that while we did
not experience complications with the monitoring segments, care should be taken to avoid obstruction at the perforator level beyond the common source vessels.
148
Microvascular Free Tissue Transfer of Previously Irradiated Flaps
Samuel Lin, MD; Beth Israel Deaconess Medical Center, Harvard Medical School; Matthew M. Hanasono, MD; The University of Texas M. D. Anderson
Cancer Center
Introduction:
Both ablative and reconstructive surgeries are more challenging in irradiated tissues. Radiation causes tissue fibrosis and intimal vascular damage, making dissection difficult and blood vessels friable and prone to thrombosis. One question that has previously not been addressed is whether tissues that have been previously irradiated can be reliably used as donor sites for free flap reconstruction.
Methods:
We performed 3 free tissue transfers in two patients who had total body irradiation (TBI) for hematologic malignancies and subsequently developed second
cancers in the head and neck. The first patient had an extensive past medical history which included acute lymphocytic leukemia, left acoustic neuroma, TBI,
and graft versus host disease (GVHD) who presented with a mandibular/facial lesion. The second patient had a history of lymphoma, previous bone marrow
transplantation and GVHD, and TBI who presented with a new right malar growth. In the setting of TBI, all potential free flap donor tissues were irradiated. In
addition, both patients had previously experienced GVHD, which is also associated with vascular damage and poor wound healing, after bone marrow transplantation.
Results:
Two patients underwent microvascular free flap reconstruction with previously irradiated tissues for oncologic head and neck defects. The first patient underwent a fibula osteocutaneous free flap and radial forearm fasciocutaneous free flap for composite mandibular reconstruction. The second patient underwent
an anterolateral thigh free flap for facial reconstruction. All three microvascular transfers of irradiated tissue survived and the patients went on to heal without
significant complications.
Conclusions:
Microvascular free tissue transfer was shown to be feasible in patients with prior TBI and GVHD following bone marrow transplantation. Our experience suggests that
even previously irradiated tissues can tolerate free tissue transfer without prohibitive technical difficulty and demonstrate reliable healing postoperatively.
Motility Differences in Free Colon and Free Jejunum Flaps for Reconstruction of the Cervical Esophagus
Institution where the work was prepared: E-Da Hospital / I-Shou University , Kaohsiung County, Taiwan
Antonio Rampazzo, MD1; Hung-Chi Chen, MD, FACS2; Bahar Bassiri Gharb1; Marcus TC Wong2; Samir Mardini, MD3; Christopher J. Salgado, MD4;
(1)E-Da Hospital / I-Shou University, (2)E-da/I-I Shou University Hospital, (3)Mayo clinic Rochester, (4)University Hospitals Cleveland / Case Western
Reserve University
Background:
Free colon and jejunal flaps have been described as reliable and safe conduits for pharyngoesophageal reconstruction. Compared with free colon flaps, free
jejunum flaps have a smaller diameter and intrinsic peristaltic movement, both of which are considered possible causes of dysphagia. In this investigation we evaluated motility differences in free jejunum and colon flaps using Radionuclide Esophageal Scintigraphy (RES).
Methods:
Patients who received free jejunum flaps (n=12) or free colon (n=1) or ileocolon flaps (n=13) for reconstruction after pharyngoesophagectomy for cancer were
included. RES was performed using Technetium-99m marked sulfur colloid. Transit rate was evaluated at 1 second (pharyngeal or initial clearance) and 10
seconds (esophageal or clearance throughout). Clinical progression of swallowing was recorded postoperatively. Statistical analysis was performed with
Student’s t-test.
Results:
Mean pharyngeal clearance was 61.05±19.83% for free colon and ileocolon flaps, and 69.0±16.25% for free jejunum flaps. Mean esophageal clearance
was 49.65±27.28% for free colon and ileocolon flaps, and 69.08±17.12% for free jejunum flaps. Esophageal transit rate was significantly shorter in patients
who were reconstructed with free jejunum flaps (p= 0.038). At one year, 10 of 12 free jejunum patients and 8 of 14 patients free colon patients were tolerating solid foods.
Conclusions:
Although neither flap showed normal swallowing characteristics, free jejunum flaps displayed greater esophageal clearance and should represent the first
choice in hypopharyngeal reconstruction. Free colon and ileocolon flaps should be reserved for very proximal oropharyngeal defects and when simultaneous
voice reconstruction is desired.
149
Reconstruction of Pediatric Cranial Base Defects: A Retrospective Review of a Single Microsurgeon’s 30-Year Experience
Institution where the work was prepared: Children’s Hospital Boston, Boston, MA, USA
Matthew J. Carty, MD1; Nalton Ferraro, MD, DMD2; Joseph Upton2; (1)Brigham and Women’s Hospital, (2)Children’s Hospital Boston
Background:
For the past 30 years, microsurgical free tissue transfer has enabled the reconstruction of pediatric cranial base lesions formerly believed to be refractory to
surgical therapy. Due to the relative rarity of these oncologic processes and the highly specialized requirements for their treatment, few large-scale reviews of
microsurgical reconstruction of pediatric cranial base lesions have been published to date.
Methods:
A retrospective review of all free tissue transfer reconstructive procedures undertaken by a single microsurgeon for pediatric cranial base defects was performed for
operations occurring between 1977 and 2007. All procedures were performed at a single institution on patients ranging from infancy to 16 years of age. Data was
culled from a combination of patient charts, hospital records, radiographic studies and clinical photographs.
Results:
Thirty patient charts were analyzed from the defined 30-year period. The average patient age at the time of diagnosis was 5.3 years (SD=4.9 years). The most
common primary diagnosis was rhabdomyosarcoma (n=10, 33%). The majority of patients received chemotherapy (n=26, 87%) or radiotherapy (n=16, 53%).
Most patients required extirpative hemi-maxillectomy or hemi-mandiblectomy, necessitating reconstruction of intraoral structures in sixteen children (53%). Forty
free tissue transfers were performed; the most commonly utilized donor site was the rectus abdominis muscle (n=19, 48%), followed by the fibula (n=13, 30%),
scapula (n=5, 13%), latissimus dorsi muscle (n=2, 5%) and radial forearm (n=1, 3%). Reconstructive adjuncts included nonvascularized bone grafts (n=13,
43%) and sural nerve grafts (n=6, 20%). Short-term perioperative complications were relatively minor; no flap losses were recorded. The most common anticipated long-term complications included growth disturbances (n=10, 33%), resorption of non-vascularized bone grafts (n=8, 27%) and soft tissue atrophy/contracture (n=8, 27%). The majority of patients studied were noted to be surviving (n=22, 73%) with an average age of 19.2 years (SD=10.1 years); among
those patients who had died (n=8, 27%), the average age at death was 14.6 years (SD=6.2 years). The preponderance of patients who had died received
their initial surgery and reconstruction during the first 15 years of this study period (n=7, 88% of subgroup), with death most often due to complications related to extension of the original malignancy through the cranial base.
Conclusions:
As advances in oncologic therapy continue to improve survival among pediatric patients suffering from malignancies involving the cranial base, microsurgery simultaneously continues to enable robust options for post-extirpative reconstruction and therefore provides a major benefit to the ongoing care of these individuals.
Mandibular Reconstruction Using Custom Made Osteotomy Templates
Ryo Hattori, MD; Ken Matsuda; Tateki Kubo; Mamoru Kikuchi; Ko Hosokawa; Sayuri Arimitsu; Tsuyoshi Murase; Osaka University
Purpose:
In most of the mandibular reconstruction surgeries using free vascularized fibula flap, one or two osteotomies are necessary to reconstruct the smooth contour of
the mandible. Although multiple segments contribute to rebuild smoother shape of the mandible, the number of osteotomies should be kept in less concerning
about segmental vascularity. Therefore, the positions and angles of the osteotomies play an important role in reconstructing mandible, especially when it is performed by means of closing wedge osteotomy. And it is also important that each segment has proper length and is fixed in proper angles. However, without any
guiding method, it is extremely difficult to perform accurate osteotomies, and in many cases surgeon needs correction osteotomies to adjust the cutting angle.
Ideally, osteotomies should be carried out in fewer times to avoid vascular damage, and correction osteotomies are not preferable. Therefore, we used custom
made osteotomy templates to facilitate osteotomies.
First, the surface data of the mandibular and fibular cortex is extracted respectively from DICOM file formatted 3D-CT data. Then, length, position of each segment, and the angle of each osteotomy plane is determined on the 3D simulation program (Fig. A). After the position and angle of each osteotomy plane is
determined (Fig. B), custom made templates are created. A few couples of guiding slits and attachment holes are designed on the template (Fig. C). Templates
are attached to the fibula and fixed by wires (Fig. D). During the osteotomies the reciprocating saw is inserted just along the guiding slits, and the operator has
only to concentrate on not to damage the vascular bundle. We performed this method to 9 patients (Fig. E, F).
Results and Conclusion:
All the osteotomies have been accomplished under the guide of the custom made templates, and these templates functioned well without any problem. Accurate
osteotomies have been carried out without any vascular damages, and the contour of the mandible was finely rebuilt. In addition, there was no necessity of
correction osteotomies in all cases.
150
Extracranial-Intracranial Bypass. A Case Series
Institution where the work was prepared: Eastern Virginia Medical School, Norfolk, VA, USA
Michael W. Chu, MD; Ran Vijai Singh, MD; J Trad Wadsworth; Eastern Virginia Medical School
Educational Objectives:
1. Understand advantages and limitations of cerebral revascularization with EC-IC bypass 2. Identify the subgroup of patients who may benefit from cerebral
revascularization Introduction: EC-IC arterial bypass, first described in 1969,has been used for a variety of pathologies, including cerebral ischemia, aneurysm,
penetrating trauma, as well as head and neck tumors requiring carotid artery resection. EC-IC bypass is used to circumvent otherwise inaccessible carotid
lesions and increase brain perfusion. However the 1985 EC-IC Bypass Trial failed to show a benefit in reducing overall mortality and stroke when compared
to medical treatment. The procedure has since fallen out of favor and remains controversial. But there may be utility of EC-IC bypass in a select subset of patients
that are high-risk or non-responsive to medical therapy. EC-IC bypass has been shown to be a safe and effective procedure in certain patients by restoring
physiologic cerebral perfusion. We report our institutional experience of 7 cases of EC-IC arterial bypass and describe the clinical, surgical, and follow-up findings. Study
Design:
Case Series
Methods:
Imaging, surgical technique, follow-up, and published literature are reviewed.
Results:
Retrospective chart review from October 2004 to May 2008 revealed seven patients who underwent seven EC-IC bypass procedures. The indications for surgery
include six cases of ICA stenosis and a case of Moyamoya disease. A total of six women and one man underwent surgical treatment. The average age was 51.4
(range 46 – 58). All patients had recurrent symptoms of hypoperfusion, including TIAs and hemiparesis, as well as occasional cases of CVAs. All patients had
superficial temporal artery to middle cerebral artery bypass. Long-term follow-up showed clinical improvement and decreased frequency of ischemic symptoms.
Post-operative complications include one left ACA infarct, one 10-month post-operative TIA that spontaneously resolved, and another patient with an asymptomatic post-operative infarct without sequelae.
Conclusions:
Our clinical series of 7 patients who underwent EC-IC arterial bypass showed the procedure to be relatively safe and effective. The procedure remains controversial for revascularization to decrease overall mortality and stroke rates. But there remains a role for bypass in certain subgroups of high-risk ischemic disease, ischemic disease refractory to medical therapy, Moyamoya disease, and head & neck cancer requiring carotid artery sacrifice. Further research is warranted to identify and characterize these subsets of patients, especially as new surgical techniques and innovative technology continue to advance microvascular surgery to improve patient outcomes.
Free Partial Superior Latissimus (PSL) Muscle Flap in Head and Neck Reconstruction
Sendia Kim, MD; Darrell Brooks, MD; Rudy F. Buntic, MD; Buncke Clinic
Background:
The latissimus dorsi muscle is often used in microvascular head and neck reconstruction. For even small to medium sized defects, however, the entire muscle is
harvested and then divided ex vivo to fit the recipient site. This may result in loss of muscle function or loss of the lateral thoracic silhouette. A free partial superior latissimus (PSL) flap keeps the lateral and inferior segments of the muscle intact, thus preserving muscle function and donor-site form. In this study the authors
examine the utility of a free PSL flap in head and neck reconstruction.
Method:
From January 2007 to May 2008 a retrospective study was performed on patients who had a free PSL flap for head and neck reconstruction. Thirteen patients
were included in our study and seen in clinic for follow-up.
Results:
Thirteen patients had a free PSL for head and neck reconstruction. Three patients required reconstruction for trauma and 10 had resections for malignancy. Eight
patients had scalp reconstructions, 3 had tongue reconstructions, 1 had tongue and floor of mouth reconstruction, and 1 patient had a chin reconstruction. The
patients ranged from 21 months to 75 years of age (mean 55.4 years). The pedicle length ranged from 7 to 16 cm (mean 9.54 cm). The flap was neurotized in 4
patients. Nine patients (69.23%) had split thickness skin grafts. One patient had a skin paddle. There were no flap failures or partial flap losses. One patient returned
to the operating room in the post-operative period for hematoma evacuation. Four patients (30.77%) required aspiration for seroma formation. The average postoperative follow up was 2.87 months.
Conclusion:
The free PSL flap is a versatile and reliable flap for small or medium size defects in head and neck reconstruction. The advantages of a PSL flap include consistent anatomy, long pedicle length, potential for neurotization, and inclusion of a skin paddle, if necessary. By keeping the lateral and inferior borders of the latissimus dorsi muscle intact, partial harvest of the muscle minimizes donor site morbidity and allows for the preservation of the lateral thoracic silhouette. In addition, the nerve supply to this area is also left intact, thereby maintaining muscle function.
151
Fingertip Replantations
Takaaki Hasuo; Komaki City Hospital; Genzaburo Nishi; Aichiken Koseiren Kainan Hospital
The purpose of this study is to examine the correlation between the presence or absence of venous anastomosis and the survival rate, to clarify the need for
venous anastomosis, and to analyze the functional results after fingertip replantations. From January 1980 to December 2005, 143 distal phalanges of completely amputated fingers in 127 cases were replanted. The average of patients was 38.1 years. There were 20 thumbs, 42 index fingers, 39 middle fingers,
28 ring fingers, and 14 little fingers involved. In terms of Ishikawa’s classification, there were 48 amputations in subzone II, 56 in subzone III, and 39 in subzone IV. We retrospectively analyzed the range of motion, sensory recovery, nail deformity, and the Disabilities of the Arm, Shoulder and Hand(DASH)test for
subjective assessment of functional recovery. The overall survival rate was 78 percent. The survival rate of replants without venous anastomosis was 80 percent
for subzone II, 83 percent for subzone III, and 0 percent for subzone IV. On the other hand, the survival rate of replants with venous anastomosis was a very
high 93 percent. The loss of the range of distal interphalangeal joint was 25 percent in subzone II, 39 percent in subzone III, and 76 percent in subzone IV.
Sixty percent of nerve repaired digits and 58 percent of nerve unrepaired digits achieved diminished light touch. All digits in the nerve repair group achieved
protective sensation. The incidence of moderate to severe nail deformity was 18 percent in subzone II, 36 percent in subzone III, and 23 percent in subzone
IV. The average DASH score was 3.6, and all of the patients were satisfied aesthetically as well as functionally with the final results. The results from this series
indicate that successful venous anastomosis is the best way to promote the survival of replanted digits. If venous anastomosis is infeasible, replanted digit in
subzone II and III can survive with any of the methods mentioned, but it does not survive in subzone IV. The loss of DIP function tends to increase, as it becomes
almost a joint, and it’s important that nerves be repaired if possible. Nail deformity of replanted digits, which level was in subzone III and type of injury was
crush, tended to increase. Fingertip replantation is a valuable procedure which provides acceptable sensibility as well as good cosmetic results.
Face Transplant for Plexiform Neurofibroma 18 Months Follow up
Institution where the work was prepared: CHU Henri Mondor Paris XII University, CRETEIL, France
Laurent A. Lantieri, MD; Philippe Grimbert; Jean Paul Meningaud; Franck Bellivier; Nicolas Ortonne; Marc David Benjoar; Pierre Wolkenstein; CHU Henri
Mondor Paris XII University
The authors present the results of a facial Composite Tissue Allotransplantation with 18 months follow up on a a 29 yo patient with plexiform neurofibroma.
The patient was operated by several plastic surgeons with no success (over 35 operations). Anatomical and technical studies completed with ethical and
immunological reviews by several expert committees resulted in an IRB approval in October 2005. The patient wascarefully reviewed by psychologist and psychiatrist before giving inform consent. The surgery took place on Sunday 21 January 2007. The excision included all soft tissue under zygomatic arch on both
side down to the neck and laterally to the ears. The face of the donor was harvested on beating heart before the other organs. End to end anastomosis was
performed on external carotid and thyrolingofacial trunk. We then performed nerve anastomosis on both facial nerve followed by both sub orbitaries nerves.
The restoration of the body was done by doing first a mold of the face with alginate. A solid mask was done during the harvest and could be put on the defect
so that the other team could harvest other organ after total repair of the face. Immunosuppression protocol associated anti lymphocyte serum for 10 days started at the time of anastomosis, Tacrolimus MMF and Steroids as in other CTA or kidney transplants. The biopsies at day 28 showed a moderate infiltration of
lymphocyte grade 1 which necessitated corticosteroid therapy. The concomitant moderate inflammation then quickly resolved. The biopsies at day 42 did not
show any more lymphocyte infiltration at the level of mucous membranes. At day 60 the patient sustained antiviral-resistant cytomegalovirus (CMV) , leading
to ganciclovir but not to cidofovir resistance, this was associated with acuted rejection which was resolutive after CMV infection treatment. Biopsies since that
episode do not show any sign of rejection. Active movement started to appear at 6 months and the patient required locale anesthesia at four month From a
psychological point of view the patient saw his new face 10 days after the intervention and seems to perfectly accept the new aspect. His general state is excellent. He is able to carry alone all the routine activites of dayly living and has started a new job. Face transplant has move from ethical debate to surgical reality. However, as in other organ transplant this procedure carries high risks and needs longtime follow-up.
Microsurgical Salvage of the Intractable Oral Vestibule
Institution where the work was prepared: Division of Plastic, Reconstructive & Maxillofacial Surgery, R A, Baltimore, MD, USA
Suhail Mithani, MD; Johns Hopkins School of Medicine; Hugo St-Hilaire, MD, DDS; R Adams Cowley Shock Trauma Center; Eduardo Rodriguez, MD, DDS;
R. Adams Cowley Shock Trauma Center
Introduction:
The significance of the oral vestibule is often underappreciated in composite craniomaxillofacial reconstruction and its deficiency results in considerable incompetence. Results of traditional vestibuloplasty techniques are often unpredictable when the recipient bed is compromised in the setting of trauma or radiation.
We present an alternative approach for restoring the intractable oral vestibule with free tissue transfer.
An IRB retrospective review of patients who underwent oral vestibular reconstruction was conducted at R Adams Cowley Shock Trauma Center and Johns
Hopkins Hospital from 2002 to 2007.
Results:
Thirteen patients were identified: six defects resulted from tumor extirpation, six from traumatic injury and one from infection. There were eight males and five
females with a mean age of 46 years. Thirteen free tissue transfers of the oral vestibule were conducted: 6 ulnar forearm and 7 anterolateral thigh perforator
flaps. The average follow up was 17 months. There were no flap failures and only one complication noted which did not result in negative sequela. The functional results were good with all patient experiencing increased labial excursion and subjective improvement in the handling of food bolus and saliva.
Conclusion:
Preservation of oral vestibular height, width and volume is essential for aesthetic appearance and functional competence. Free tissue transfer provides an innovative alternative in the management of the intractable and obliterated oral vestibule. It can be performed successfully, providing excellent results predictably.
152
Total Maxillary and Inferior Orbit Reconstruction with Fibula Osteocutaneous Flaps
Michael Fritz, MD1; Steven Cannady, md2; Joseph Scharpf, MD1; Robert Lorenz, MD3; (1)The Cleveland Clinic Foundation, (2)Cleveland Clinic,
(3)Cleveland Clinic Foundation
Background:
Total palatomaxillary defects pose a significant challenge for reconstructive surgeons, particularly when the orbital floor and rim are included in the resection.
Reconstructions using both soft tissue and composite free tissue transfers have been described in the past with variable outcomes regarding postoperative aesthetics, maintenance of orbital position and function, and masticatory ability. The purpose of this study was to evaluate and describe the utility of a consistent
and novel method of using fibula osteocutaneous flaps to optimize outcomes on all fronts.
Methods:
This is a retrospective series of 5 patients with Brown class IIIa or larger defects who underwent primary reconstruction using stacked fibula osteocutaneous
flaps. Patients were reconstructed using fibula in three or four segments spanning from lateral orbital rim to nasofacial sulcus, then reflecting back at a lower
level from the medial vertical buttress to the zygoma near the lateral orbital rim. This method allowed for inferior rim and upper maxillary reconstruction, and
established a strong foundation by recreating the medial and lateral vertical butresses. In all cases, the maxillary cavity was obliterated with vascularized soft
tissue from the flap and the palate was reconstructed with the remaining fibula skin paddle. Dacryocystorhinostomy, orbital floor reconstruction, and aggressive suspension of the lower eyelid were performed at the same setting. Three patients underwent postoperative radiation therapy. Patient follow-up ranged
from 6 months to 3.5 years. Functional outcomes in terms of aesthetics, visual function, speech, oral diet and dental restoration were assessed.
Results:
Excellent aesthetic and functional outcomes were obtained in 4/5 patients. The fifth patient experienced rapid disease progression following postoperative
chemoradiation therapy and succumbed to disease. No long term visual disturbance was observed. Harvest site morbidity was minimal and no flap failures
occurred. The most common postoperative complication was ectropion, which was observed in 4/5 patients and successfully corrected with revision surgery.
Two patients have undergone rehabilitation with osseointegrated implants to date. Two others plan to pursue this route in the future.
Conclusions:
Stacked fibula osteocutaneous flaps provide an ideal method for repairing large palatomaxillary defects which involve the orbit. Excellent functional and aesthetic results can be consistently obtained with potential for dental implant rehabilitation and minimal donor site morbidity.
153
ASRM - Clinical Extremities II
Distal Phalanx Replantation Using the Delayed Venous Method: a High Success Rate in 33 Cases
Institution where the work was prepared: Makoto Mihara, Tokyo, Japan
Makoto Mihara, MD; Mitsunaga Narushima; Isao Koshima; Tokyo University
Background:
The purpose of the study was to show that the delayed venous method provides a high success rate in distal phalanx replantation, and does not require use of
specialized techniques. Vein anastomosis is the most important factor determining the “take rate” in treatment of distal phalanx amputation. However, blood
flow in the distal phalanx subdermal vein is lost immediately after an accident, making it difficult to find the collapsed vein and to perform vein anastomosis in
the initial surgery. Therefore, we have chosen to perform a two-stage surgical procedure, and we have obtained excellent results with this method.
Methods:
The two-stage delayed venous method for vein anastomosis was first reported in 2003. This surgical procedure includes initial arterial anastomosis, delayed
expansion of the vein, and subsequent vein anastomosis in a second surgery.
Results:
The delayed venous method was used in 33 cases. Expansion of veins of up to 1 mm or more resulted in a high success rate (84.8%) in procedures performed
by a junior micro-surgeon. In contrast, the success rate for distal phalanx replantation is extremely low in other techniques because of difficulty with vein anastomosis.
Conclusions:
The delayed venous method allows relatively easy anastomosis of the subdermal vein of the distal phalanx. Furthermore, the procedure was performed by a
junior micro-surgeon with less than two years of experience, showing that the method does not require special training. Therefore, it is a useful operative technique for treatment of amputated fingers by a non-specialized plastic surgeon.
Pediatric Vascular Emergencies: The Need for Microsurgical Expertise
Institution where the work was prepared: Children’s Hospital of Philadelphia & University of Pennsylvania, Philadelphia, PA, USA
Adam J. Kaye, MD1; Alison E. Kaye, MD1; Thane A. Blinman, MD2; Michael I. Nance, MD2; Patrick K. Kim, MD1; Benjamin Chang, MD1; (1)University of
Pennsylvania, (2)Children’s Hospital of Philadelphia
Background:
Pediatric vascular injuries are rare, but serious events. When they occur, the trauma is often life or limb threatening. The relative infrequency of pediatric vascular cases, specifically, peripheral vascular injuries, has historically meant a lack of subspecialty training or uniformity in operative management in these challenging patients. Depending on the institution, size of patient, and anatomical region, these cases may be treated by a variety of surgical sub-specialists.
Methods:
To understand current practices in the management of pediatric peripheral vascular trauma we performed a 10-year retrospective review of patients treated at neighboring level I trauma centers. For each case the use of microvascular techniques for repair was noted. Additionally, a nationwide survey of pediatric surgeons was
performed to determine the larger pediatric vascular trauma experience and subspecialty care of patients.
Results:
34 patients with 43 peripheral vascular injuries aged 1 month to 18 years were identified. Patients were predominantly male, averaging 13.7 years; females
averaged 7.5 years (p<0.009). Injuries included penetrating (67.6%), blunt (17.6%,), and iatrogenic (14.7%) events. Procedures involved the lower extremity in 68% and upper extremity in 32% of patients. 23 pre-operative imaging studies were performed including angiogram, CTA, MRA, and ultrasound.
Ultimately, 16 vessels were repaired directly or patched while 12 vessels required interposition or bypass grafting for reconstruction. 15 patients (44%) required
microsurgical techniques for 17 vessel repairs or reconstruction. Nationwide survey respondents included 168 surgeons from 107 institutions. Over two-thirds
of respondents reported seeing less than 10 vascular trauma patients yearly. The management of patients varied widely for each hospital and vascular issue.
Conclusions:
Our series describes a small, but significant number of urgent pediatric vascular injuries, often using microsurgical techniques for management. Facility with
small vessel size and vein grafting was important as 41% of surgeries were for preadolescent children. Nationwide survey results indicate there is not a predictable group of physicians taking responsibility for these patients suggestive of inconsistent training and general discomfort with these patients’ combined surgical challenges. The frequent involvement of microvascular surgeons in operative management indicates a need for microsurgical expertise when treating
this patient population.
Vascular Problem
Pediatric Surgery
Vascular Surgery
Cardiac Surgery
Adult Trauma
Plastics, IR, Ortho, etc
Traumatic Aorta
41.8%
32.2%
9.1%
8.8%
8.1%
Elective Aorta
19.5%
54.5%
20.3%
0.0%
5.7%
Traumatic Upper Extremity
33.8%
39.5%
3.2%
7.3%
16.3%
Traumatic Lower Extremity
35.4%
42.8%
3.5%
7.0%
11.3%
Elective Extremity
22.3%
60.3%
7.4%
0.0%
9.9%
154
The Posterior Tibial Artery Perforator Flap: An Alternative to Free Flap Closure in the Comorbid Patient
Institution where the work was prepared: Beth Israel Deaconess & Massachusetts General Hospital, Boston, MA, USA
Brian M. Parrett, MD1; Jonathan M. Winograd2; Samuel J. Lin, MD3; Loren Borud, MD3; Amir H. Taghinia, MD4; Bernard T. Lee, MD3; (1)Harvard Plastic Surgery, (2)Massachusetts
General Hospital, Harvard Medical School, (3)Beth Israel Deaconess Medical Center, Harvard Medical School, (4)Children’s Hospital and Harvard Medical School
Wounds of the distal third of the leg with exposed bone traditionally require free flap coverage. However, patients with multiple comorbidities may not be able to undergo the
long operating times and multiple surgical sites required for these complex procedures. We sought to determine if the posterior tibial (PT) artery perforator flap can provide
wound closure in these comorbid patients with comparable results to free flap closure.
From 2003-2007, we identified all patients who had distal leg wounds treated with a PT perforator flap after they were deemed not suitable for a free flap due to medical or psychiatric comorbidities. Charts were retrospectively reviewed for demographics and flap details. Outcomes assessed included flap complications, wound and
donor site complications, operative time of flap procedure, need for additional procedures, mal-/nonunion rates, and ambulation status.
Eight patients (mean age, 59 years) with multiple comorbidities that precluded free flap closure were treated with PT perforator flaps to cover complex distal leg wounds. Four
patients had significant cardiac disease, 2 had peripheral arterial disease with one-vessel run-off to the foot, and 2 had uncontrolled psychiatric illnesses. Five patients had acute
Gustilo grade IIIB open tibial fractures and three had chronic wounds with exposed bone. Mean flap size was 8 x 5.5 cm with a mean of one perforator per flap. Five flaps were
pedicle rotational or transposition flaps and three were island flaps. Mean operating room time was 103 minutes. Five flaps were performed with femoral blocks or under local
anesthesia with sedation. There were no perioperative cardiopulmonary events and no patients required ICU monitoring. With a mean follow-up of 15 months, all flaps survived
and all patients were ambulatory. There were two cases of venous congestion, both in island flaps, which resolved without further treatment. There were no cases of malunion,
nonunion, infection, wound breakdown, or partial flap loss.
The PT perforator flap is a reliable choice for patients with open leg wounds and comorbidities precluding free flap closure. The PT perforator flap has allowed us to cover complex wounds with a short operative time, minimal complications, and often without the need for general anesthesia.
A Novel Subunit Based Approach to Limb Salvage for Foot and Ankle Wounds
with Free Tissue Transfer: A single institutions 10-year experience of 165 free flaps
Institution where the work was prepared: Duke University Medical Center, Durham, NC, USA
Scott T. Hollenbeck, MD; Shoshana Woo, BS; Detlev Erdmann, MD, PhD; Michael, R. Zenn, MD; L. Scott Levin, MD; Duke University
Purpose:
Free tissue transplantation to the distal lower extremity can be a powerful tool for the reconstructive microsurgeon. Long term follow-up and critical analysis of outcomes
is needed to further define patient selection, choice of donor site, expected complications and limb salvage rates.
Methods:
The IRB approved the retrospective review of 161 patients who underwent free tissue transplantation for foot and ankle wounds between 3/01/1997 and 2/28/2007.
Results:
Of 161 patients identified, there were 165 free flaps performed. The mean age of the patient population was 38.1 years (range: 1 – 75). Of these patients; 32% were female,
27% had osteomyelitis, 17% had hypertension, 15% had diabetes and 5% had clinically significant coronary disease. The most common types of wounds treated with free flaps
were trauma related (n=120, 75%), diabetes related (n=24, 15%) and melanoma excisional defects (n=8, 5%). For acute trauma patients, mean time from injury to free flap was
12.1 days (range 2-30). Of all patients, 84 had ankle wounds and 77 had foot wounds. These defects were further characterized by a novel subunit classification for the foot
and ankle (Fig 1A). A total of 10 different donor sites were used for these defects, with latissimus dorsi being the most common (Fig1B and 1C). Fifty-five patients sustained a
complication which required intervention, the most common of which was partial flap ischemia or wound breakdown (n=15). Overall flap survival rate was 92%. Twenty patients
required re-exploration for flap salvage with venous thrombosis being the most common cause of flap struggle (n=11, 55%). Mean follow-up from time of free flap was 25.3
months (range: 1 – 115). Ultimately, 11 patients (6.8%) underwent extremity amputation at a mean time of 9.7 months (1-39 months) after primary free flap. The overall 5-year
limb salvage rate as determined by Kaplan-Meier analysis was 89%. There was no significant difference in the limb-salvage rate for patients with foot or ankle wounds. Patients
with diabetes (Fisher Exact, p<0.05) and those with primary flap failure (Fisher Exact, p<0.05) were at increased risk for limb loss. Other factors did not significantly impact limb
salvage.
Conclusion:
The use of free tissue transplantation for treatment of severe foot and ankle wounds results in an excellent rate of limb salvage. Overall, the presence of diabetes and primary flap failure portends a worse prognosis.
155
Wide Combined Thin Free SCIA/SIEA Flap
Institution where the work was prepared: Hacettepe University, Ankara, Turkey
Serdar Nasir, MD1; Mustafa Asim Aydin, MD2; Tunc Safak, MD1; Abdullah Kecik, MD1; (1)Hacettepe University, (2)Suleyman Demirel University
Introduction:
Thin flaps are preferred for some reconstruction of the hand and wrist, the foot and ankle, and the neck and cheek. One-stage coverage may be applied using
an extremely thin and large flap. In the past, some surgical techniques for free flap types such as microdissection and super microsurgery reported the need
for flap thinning. Although uniformly thin perforator flaps were achieved with these techniques, the need for advanced microsurgical skill is a disadvantage in
reconstructive surgery. To facilitate flap thinning, we used simple method for free SCIA/SIEA flap. In this study we present details of our thinning methods for
free SCIA/SIEA flap.
From 2003 to 2006, 11 patients with a mean age of 37 years(range, 16 to 68) underwent attempted reconstruction with thinned free SCIA/SIEA flaps and
11 transfers were performed. Nine of 11 patients were men and two were women. The flap ranged from 10 to 60 cm in length and from 6 to 55 cm in width.
In our flap thinning technique, the deep subcutaneous adipose tissue was removed with tissue scissors, beginning from the periphery and stopping 1 cm from
the location where the pedicle enters the fat layer. Generally the fat lobules of deep adipose layer are larger than those of the superficial adipose layer and
these large fat lobules were removed easily by the scissor using the naked eye. The superficial adipose layer composed of the small and tight small fat lobules
was then carefully thinned evenly, except for 2 to 3 cm diameter area around the entrance of the pedicle into the flap. Therefore, approximately 3 to 5 mm of
superficial fat layer was protected under the skin.
Withdrawn
Results:
Ten flaps survived completely and one occurrence of superficial necrosis was observed. The skin defect underwent secondary healing without the need for additional intervention. No further flap revision or defatting procedures were required for these patients during an average 12 months’ follow-up(range, 7 to 16).
The functional and aesthetic results were evaluated as acceptable by all patients.
Conclusion:
Free SCIA/SIEA flap is a useful alternative with a wide skin island, minimal donor site morbidity, and simple surgery in reconstructive surgery. Although it is
bulky flap, especially for obese patients, it may be thinned using the naked eye. Furthermore successful functional and esthetic results with thin free flaps for
special localization such as hand, foot, and oral lining may be achieved.
Distally Based Sural Fasciomyocutaneous Flap: Anatomic Study and Modified
Technique for Complicated Wounds of the Lower Third Leg and Weight Bearing Heel
Institution where the work was prepared: Tongji University, Shanghai, China
Shi-Min Chang, MD; Kai Zhang, PHD; Tongji Hospital, Tongji University
Background:
Repair of the distal third leg and weight-bearing heel, especially when complicated with infection and/or deep dead space, remains a challenge in reconstructive surgery. In this paper, the authors describe a modification to harvest the distal portion of gastrocnemius as an attached muscle flap with a shorter fasciocutaneous carrier, and thus reduce the donor site incision and morbidity.
Methods:
The study was divided into two parts, anatomic study and clinical applications. In Part One, six fresh lower legs were injected with red gelatin and all musculo-fasciocutaneous perforators of the overlapping area between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle were identified.
In Part Two, based on anatomic study, six clinical cases of complicated wounds were reconstructed with the distally based sural fasciomyocutaneous flap.
Results:
The anatomic study showed that there are constant vascular connections (usually 4 musculo-fasciocutaneous perforators with diameter <0.5mm) of the overlapping area (4cm long in average) between the suprafascial sural neurovascular axis and the deep gastrocnemius muscle. Clinically, six patients with distal
lower leg osteomyelitis after open fracture (4 cases) and plantar heel (2 cases) pad defects were treated with the flaps. The fasciocutaneous flap size ranged
from 8cm x 5cm to 12cm x 9cm, with adipofascial pedicles 4 to 6 cm in length and 3 to 4cm in width. The attached muscle flaps beneath the deep fascia
ranged from 4cm x 3cm to 7cm x 5cm, with 1cm to 2.5cm in thickness. Two mode of distal pedicle were used, the perforator-plus adipofascial (3 cases) and
the pure perforator (3 cases). All the flaps survived without complications.
Conclusions:
Distally based sural fasciomyocutaneous flap provides bulk and viable high metabolic muscle. It has the potential to provide sensation, and can be performed
in a single stage without microsurgical technique. It should be considered of choice when the lower leg wound is complicated with osteomyelitis and/or dead
space, or the weight-bearing heel pad is completely destroyed.
156
Comparison of Different Management of Large Superficial Veins in Distally Based Fasciocutaneous
Flaps with a Veno-Neuro-Adipofascial Pedicle: An Experimental Study in the Rabbit Model
Institution where the work was prepared: Tongji Hospital, Tongji University, Shanghai, China
Shi-Min Chang, MD1; Yudong Gu, MD2; Ji-Feng Li1; (1)Tongji Hospital, Tongji University, (2)Huashan Hospital, Fudan University
Background:
Extensive clinical applications of distally based veno-neuro-fasciocutaneous flaps without thorough experimental studies might be one of the reasons for their
frequent complications. The role of large superficial veins in survival of distally based fasciocutaneous flap with a veno-neuro-adipofascial pedicle was studied
in a rabbit model.
Methods:
A sural veno-neuro-fasciocutaneous flap model (6?2cm) with distally based lesser saphenous veno-neuro-adipofascial pedicle (1.5cm) was established. Fifteen
rabbits were randomly divided into 3 groups with 10 flaps in each group. In group I, the distal lesser saphenous vein was left opened (venous inflow remained)
after the flap was raised. In group II, the lesser saphenous vein was ligated in the pedicle (no venous inflow). In group III, the venous pedicle was left opened
in the pedicle, and the proximal end was microsurgically anastomosed to the recipient vein (outflow established). The intravenous pressure, flap survival and
histology were examined.
Results:
The results showed that the values of intravenous pressure in group I were significantly higher than that in group II (p<0.001). The mean flap survival rate of
group III (94.5%) was significantly higher (p<0.001) than that of groups I (22.7%) and II (55.5%). Histology showed that the lesser saphenous vein in groups I
was extremely dilated and filled fully with thrombosis.
Conclusions:
This experiment demonstrated that establishing a superficial venous outflow channel by anastomosis at the proximal end, or interrupting the inflow channel by
ligation at the distal pedicle may significantly improve the survival rate of distally-based veno-neuro-fasciocutaneous flaps
Risk Analysis for the Reverse Sural Fasciocutaneous Flap in Distal Leg Reconstruction
Institution where the work was prepared: Brigham & Women’s Hospital, Boston, MA, USA
Brian M. Parrett, MD1; Evan Matros, MD1; Julian J. Pribaz, MD2; Wojtek Przylecki, MD1; Christopher E. Sampson, MD3; Dennis P. Orgill, MD, PhD4;
(1)Harvard Medical School, (2)Brigham and Women’s Hospital, Harvard Medical School, (3)Brigham & Women’s Hospital, (4)Harvard University
Literature for the reverse sural fasciocutaneous flap (RSFF) in distal leg reconstruction reports low complication rates, but focuses on young, healthy patients with
traumatic wounds. Given the more widespread use of the RSFF in older patients with comorbidities, we hypothesize that there is a higher complication rate.
Fifty-eight consecutive RSFF performed from 1994 to 2003 were retrospectively reviewed for patient and wound characteristics as well as major (flap loss or
partial loss >20cm2 requiring a secondary coverage procedure or amputation) and minor (marginal necrosis, wound/flap breakdown) complications.
Outcomes were compared between patients with no comorbidities (n=31) and those with a history of smoking, diabetes mellitus, or peripheral arterial disease
(n=27). Standard statistical analyses were performed including logistic regression.
Mean age was 53 years and the most common wound etiologies included incision breakdown/infection after surgical procedures, open fractures, and ischemic
ulcers; all wounds were located in the distal third of the leg. Median follow-up was 20 months. A total of twenty-nine flaps (50%) had post-operative complications with 8 (14%) major complications (3 total flap losses, 5 partial losses), 18 (31%) minor complications, and 3 infections. In patients without medical comorbidities, there were no major flap complications and 5 minor complications (16%) requiring secondary coverage procedures. Comparatively, patients with history of either smoking, diabetes, or peripheral arterial disease had a significantly higher rate of complications (78%, p<.0001); in this group, 74% of flaps needed surgical revisions, including 2 free flaps, 3 amputations, and multiple skin grafts. Advanced patient age greater than 70 years was also associated with an
increased complication rate (p<.05). Multivariate regression analysis identified smoking history as the risk factor independently associated with any sural flap
complication (p=.006). In a subgroup analysis of patients with comorbidities, surgical delays significantly decreased the number of ischemic complications
(p=0.04).
Although the RSFF is reliable in young healthy patients, it has significant complication rates in patients with medical comorbidities, especially smokers. In such
patients, wound coverage with the RSFF often requires multiple operative revisions and a surgical delay is recommended to decrease complications.
Clinical Application of Bone Marrow Stromal Cells to Avascular Necrosis of the
Femoral Head Combined with Vascularized Iliac Bone Graft
Institution where the work was prepared: Department of Orthopedic Surgery, Kyoto University, Kyoto, Japan
Ryosuke Ikeguchi, MD1; Ryosuke Kakinoki, MD, PhD1; Tomoki Aoyama, MD, PhD1; Koji Goto, MD, PhD1; Taira Maekawa, MD, PhD2; Takashi Nakamura,
MD, PhD1; Junya Toguchida, MD, PhD1; (1)Kyoto University, (2)Kyoto University Hospital
Avascular necrosis of the femoral head commonly occur in patients with two to four decades, causing severe musculoskeletal disability. Although its diagnosis
is easy with X-ray and MRI, there has been no gold standard invented for treatment of this disease. Joint replacement surgery is advantageous for pain relief
in older patients however, for younger patients the outcomes are catastrophic because of multiple revision surgery. For these patients, joint salvage procedures
seem to promise better prognosis. Vascularized bone graft to the femoral head is a powerful tool as a joint preservation procedure. However, it is sometimes
considered to be insufficient to bear the body weight in patients with the large necrotic area. Moreover, such surgical treatment may still be a challenge for the
advanced disease.
Mesenchymal stem cells (MSCs) represent a stem cell population in adult tissues that can be isolated and expanded in culture, and differentiate into cells with
different nature. It is reported that the transplantation of MSCs to an environment enabling them to differentiate into bone-lineage cells, is a promising procedure to treat several pathological osseous conditions, including avascular necrosis of bone. In our previous study, we created a canine Kienbock model and
reported that autologous MSCs transplantation combined with vascularized bone graft prevented the collapse of necrotic bone and contributed to the rapid
regeneration of bone tissues. Based on our experimental results, we started the clinical application of MSCs to avascular necrosis of the femoral head.
Autologous MSCs are harvested from the iliac bone one month before the transplantation and expanded in vitro under the sterilized condition. During the operation the vascularized bone graft pedicled by deep circumflex iliac artery and vein is harvested from the ipsilateral iliac crest. The hip joint is exposed using Smith
Petersen anterior approach and the necrotic bone is curetted from the window made just below the femoral head under the control of an image intensifier. The
expanded 5X107 MSCs are mixed with â-tri-calcium phosphate and transplanted into the created cavity. The vascularized iliac bone graft was inserted into the
cavity to provide vascularity and mechanical support to the mass containing MSCs.
We would like to present our novel method of implantation of the expanded MSCs combined with the vascularized iliac bone graft into the osteonecrotic lesion
of the femoral head to treat avascular necrosis of the femoral head.
157
Microsurgical Partial Toe Transfer Combining with the Finger Arterial Flap
Institution where the work was prepared: Saitama Hand Surgery Institute, Saitama, Japan
Yuichi Hirase, MD1; Tadao Kojima, MD1; Keizo Fukumoto, MD1; Mahito Kuwahara, MD2; (1)Saitama Hand Surgery Institute, Saitama Seikeikai Hospital,
(2)Saitama Hand Surgery Institute
For aesthetic and functional reconstruction of fingertip, the classification of amputation level should be strictly made to consider the operative pocedure. In the
case which more than a half of the distal phalanx and the nail matrix are lost, the most adequate reconstructive method is combination of the partial toe transfer including nail and the finger arterial flap which is made in the recipient site.
Materials and Method:
Indication of this procedure is the case whose nail matrix and more than half of the distal phalanx are lost. From the lateral side of the great toe,the partial toe
including adequate size of the nail and distal toe phalanx bone is harvested with the short pedicle of the toe artery. In this flap, the plantar toe nerve and the
dorsal cutaneous vein are included. In the recipient site, the finger arterial flap is elevated and advanced to the fingertip. As the finger arterial flap, the palmar
advancement flap or the oblique triangular flap is selected. The bone in the partial toe flap is fixed with the remained bone in the recipient finger and the partial toe flap is combined with the finger arterial flap to create the new fingertip. The toe artery in the flap is anastomosed with the digital artery and the toe
nerve is sutured with the digital nerve. Venous drainage is done by anastomosis of cutaneous veins between the partial toe flap and the recipient site. The donor
site of the partial toe flap is covered by the artifitial dermis and skin graft is done on it a few weeks later under local anesthesia.
Results:
This procedure is performed for 94 cases. All flaps survived except 4 cases of the partial flap loss.
Conclusion:
Combination technique of two flaps may be more difficult than the whole toe transfer or the conventional wrap-around flap. However, in this procedure the
donor site damage is less than other procedures because the harvesting volume from the toe is smaller than other procedures. And the final aspect of the fingertip is more beautiful in this procedure because there is enough volume of soft tissue in the fingertip.
Unilateral Longitudinal External Pudendal Artery Perforator Flap – A New
Technique for Reconstruction of Congenital Vagina Agenesis
Institution where the work was prepared: Chang Gung Memorial Hospital , Taoyuan, Taiwan
Jung-Ju Huang1; Chien-Min Han, MD2; Chyi-Long Lee, MD, PhD2; Ming-Huei Cheng1; (1)Chang Gung Memorial Hospital,
(2)Chang Gugg Memorial Hospital
Background:
Vaginal agenesis is a rare congenital anomaly. Traditional treatments include non-surgical regular dilatation and neovaginal skin graft followed by regular
vaginal dilatation. However, vaginal contracture is often inevitable especially in patients with poor compliance of regular dilatation. Many reconstructive options
had been introduced to achieve a nature neovagina without the requirement of regular dilatation, including various segments of intestine or colon, fasciocuatneous flaps and myocutaneous flaps. Using intestinal flaps requires abdominal surgeries, which has potential donor site morbidities including a longitudinal
unpleasing scar, intestinal obstruction and adhesion. Pedicled pudendal thigh flap and gracilis myocutaneous flaps are commonly performed fasciocutaneous
and myocutaneous flaps. However, “bilateral” flaps are usually required to achieve adequate vaginal diameter while using these two flaps for vaginal reconstruction. To eliminate the morbidities from abdominal surgery and to preclude the usage of “bilateral” flaps, we developed a unilateral longitudinal external
pudendal artery perforator flap for reconstruction of congenital vaginal agenesis.
Case Presentation:
A 12-year-old girl with congenital vagina agenesis presented with chronic abdominal pain and primary amenoria. Neovagina was created by releasing the
vesicorectal space. After the neovaginal space creation, a perforator around the upper inner left thigh was detected by hand-held Doppler and a hairless fasciocutaneous flap of 4x15 cm was designed longitudinally based on the external pudendal artery. The flap was sutured as a tube-shape and rotated into the
vesicorectal space. The internal orifice of tube flap was sutured to cervix and external orifice was sutured to vagina. The donor site was closed primarily. No
postoperative regular dilatation was required to maintain vaginal patency. Patient tolerated the postoperative course uneventfully. The menstruation turned normal after the reconstruction.
Summary:
Pedicled unilateral longitudinal external pudendal artery perforator flap is a reliable, thin and pliable flap from upper medial thigh. It has adequate flap size
to achieve good result of vaginal reconstruction with minimal donor site morbidity.
Experience with the Adductor Magnus Free Flap
Institution where the work was prepared: The University of Texas at Houston, Houston, TX, USA
Emmanuel G. Melissinos, MD; University of Texas Health Science Center; Donald H. Parks, MD; University of Texas at Houston
Purpose:
To present our experience with the use of the adductor magnus free flap in cases where the gracilis is found unsuitable for transfer and as a “free hand” flap.
The adductor magnus free flap was developed as a “back-up” flap in cases where the the gracilis muscle was found unsuitable for transfer. During a 27-year
experience, 192 gracilis free flap transfers were attempted. The size of the branches of the medial circumflex femoral vessels supplying the gracilis muscle was
found to vary considerably, but in most (184) cases was judged adequate for transfer. In eight occasions (4.16%) it was detected intraoperatively that the main
blood supply to the gracilis originated from multiple branches of the superficial femoral vessels. The caliber of the division of the medial circumflex femoral artery
to the gracilis muscle was found to be extremely small (less than 1 mm in diameter), rendering the gracilis unsuitable for use as a free flap. Lack of a better donor
site due to a combination of spinal, intraabdominal, and upper extremity injuries, prompted further dissection of the local vascular distribution, revealing that the
caliber of the vascular pedicle to the adjacent adductor magnus was much larger than that of the gracilis muscle and varying between 2.5-3.5 mm in diameter.
The medial muscle fibers of the adductor magnus centered on the vessels were harvested and transplanted successfully for reconstruction of lower extremity soft
tissue defects. With gained experience, in the last five years we have also used the adductor magnus primarily as a partial thickness “free hand” free flap in nine
cases. Follow up of 7 months to 22 years demonstrated no detectable morbidity from the procedures.
Conclusions:
Based on our experience, it is recommended that in rare cases where the main vascular pedicle of the gracilis muscle is found to be small and not useful for
free flap reconstruction, the vascular distribution to the adjacent adductor magnus muscle should be examined. If suitable, the adductor magnus can be used
safely and reliably averting the need to abandon the procedure for a new harvest site. In addition, the location of the vessels on the surface of the muscle, unrelated to the nerve supply, make it suitable for “free hand” transfer.
158
ASRM - Clinical Head and Neck II
The Scapular Tip - Angular Artery Free Flap: A New Option in Maxillary Reconstruction
Nitin A. Pagedar, MD; Rajan S. Patel, MD, FRCS; David P. Goldstein, MD, FRCSC; Jonathan C. Irish, MD, FRCSC; Dale H. Brown, MD, FRCSC; Patrick J. Gullane,
MD, FRCSC; Ralph W. Gilbert, MD, FRCSC; University of Toronto
Introduction:
Reconstruction of maxillectomy defects remains difficult for head and neck surgeons. Maxillary prostheses have long been the mainstays of treatment, but free tissue transfer has
been used for extended maxillectomy defects lacking structural elements to adequately support a prosthesis. This paper describes a single institutional experience with a novel reconstructive approach to maxillary reconstruction utilizing the scapular tip flap, based on the angular branch of the thoracodorsal artery.
Methods:
All patients in whom a scapular tip flap was used were identified in our ethics board-approved prospectively maintained free flap database. Data was collected on extent of
ablative procedures, patient comorbidities, perioperative complications, and the following outcome measures: nature of oral diet, dental rehabilitation, flap complications, shoulder function as evaluated by the DASH (Disability Assessment Shoulder Hand) scale.
Results:
Between 2002 and 2007, 30 patients underwent maxillary reconstruction with the scapular tip flap. The mean age was 65 years (range 40-79). There were five patients
with cutaneous malignancies requiring maxillectomy and one with a sinonasal lesion; all other lesions originated in the oral cavity. The bone segment was used to reconstruct either the palate or the anterior face of the maxilla and orbital floor. The majority of defects were Okay class III. There were no flap failures; one patient underwent
successful re-exploration for venous thrombosis. There were no instances of significant perioperative donor site complications. There were four major medical complications, including pneumonia and cardiac arrhythmia. Mean hospital stay was 13.6 days (range 6-35). All patients resumed a full oral diet, and no patient required gastrostomy placement. Eight of the 30 patients have undergone comprehensive dental rehabilitation, two with adjunctive osseointegrated implants. There were two oronasal
fistulas, both of which were amenable to closure with local rotation flaps. The vast majority of patients regained normal donor site motion and function as evaluated by
the DASH.
Discussion:
This study has demonstrated that the scapular tip flap offers a reliable and effective means of repairing complex defects midface and maxilla. This flap has the appropriate volume of
bone and muscle to allow reconstruction of the most complex maxillary defects with the benefits of limited donor site morbidity and a long vascular pedicle.
Microvascular Free Flap Reconstruction Versus Palatal Obturation for Maxillectomy Defects
Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA
Mauricio A. Moreno; Roman J Skoracki; Ehab Y Hanna; Matthew M. Hanasono, MD; The University of Texas M. D. Anderson Cancer Center
Introduction:
The optimal type of rehabilitation for maxillectomy defects is controversial. Few studies have compared the functional results of microvascular free flap reconstruction to
palatal obturation. Also, free flap reconstruction is thought by some to delay the diagnosis of a local recurrence.
Methods:
One hundred-fourteen consecutive maxillectomies were performed at a tertiary cancer center between 2000 and 2006. Defects were classified according to the systems
described by Okay et al. and Brown et al. Postoperative speech intelligibility, diet, and complications as well as the method utilized to diagnose recurrences were evaluated as outcomes.
Results:
Patients ranged in age from 9 to 88 years (median: 54 years). The most common primary tumor sites were the maxillary sinus (37%), the hard palate (25%) and maxillary gingiva (22%). Twelve patients received preoperative radiotherapy and 69 received postoperative radiotherapy. Vertical defects (Brown classification) included 59
patients with type II defects, 33 with type III, and 22 with type IV. Palatal defects (Okay classification) included 2 patients with type Ia defects, 33 with type Ib, 52 with type
II and 27 with type III. Seventy-three patients received an obturator and 41 were reconstructed with a free flap. Free flaps included: anterolateral thigh (n=14), fibula osteocutaneous (n=14), rectus abdominis (n=11), radial forearm (n=3), lateral arm (n=1), serratus with rib (n=1). Three patients underwent reconstruction with double free flaps
(anterolateral thigh and fibula osteocutaneous). More extensive defects were associated with the use of free flaps instead of obturators (p=0.001). There were two free
flap failures (4.8%) and the most common complication was nasocutaneous fistula (19%). Local recurrence was diagnosed by physical examination in 9 of 15 cases in
the obturator group, versus 8 of 13 cases of the free flap group (p=1.0); the remainder were detected by routine follow-up imaging studies (CT and/or MRI). No statistically significant differences in postoperative speech and diet were found between the two groups. Postoperative speech quality was affected by the extent of the palatal
defect (p=0.004) but diet was not, while the vertical extent of the defect did not affect these outcomes.
Conclusions:
Free flaps are a reliable and oncologically sound method of reconstructing maxillectomy defects, particularly for larger defects, which often cannot be obturated stably with a palatal
prosthesis. Although free flaps were most often utilized to address larger defects, the functional outcomes are comparable to those in patients who received an obturator alone.
Long Term Follow Up of Microsurgical Correction of Facial Asymmetry
Institution where the work was prepared: Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, NY, USA
Daniel J. Ceradini, MD1; Pierre B. Saadeh1; John W. Siebert, MD2; (1)New York University Langone Medical Center, (2)University of Wisconsin
Free tissue transfer is a powerful technique to correct facial asymmetry arising from multiple etiologies. The long term aesthetic outcome of this method of reconstruction
is not well described. Here we examined the longevity of microsurgical reconstruction for facial asymmetry over 15 years following surgery, and present the resulting evolution of surgical technique.
Patients undergoing free tissue transfer for facial asymmetry by a single surgeon (JWS) prior to 1993 were retrospectively reviewed using serial standardized photographs,
clinical examination, and medical records. Blinded observers were used assess changes of facial volume and distribution of tissue over time.
Forty five patients (age 6-65yrs) underwent thirty eight parascapular, four SIEA, two myocutaneous, five muscle, and 4 fasciocutaneous flaps using the superficial temporal recipient vessels. In the early experience, flap revision was performed in 39% of patients, and was not associated with flap selection. The later experience, including recent cases, flap
revision is nearly universal to optimize the aesthetic result and are most often performed at least six months following the original procedure. The most common types of revision
were periorbital tissue rearrangement and lateral excision/resuspension. Rotation advancement, elevation/resuspension, or turnover flaps were also used frequently. Descent of
the malar prominence and excess bulk at the jawline were the most frequent long term changes. There was no correlation between type of flap used and long term ptosis. Flap
volume remained constant over time. In pediatric and adolescent patients, flap revision most often resulted from growth and redistribution of tissue volume of the unaffected side.
In adult patients, revision most often correlated with weight change or age-associated ptosis of the unaffected side. Due to more rapid descent of native facial tissues, a number
of older patients requested unilateral facialplasty of the unaffected side.
Microsurgical correction of facial asymmetry undergoes predictable changes over longer periods of time reflecting the aging of tissue. While descent of soft tissue remains a common age-related change between native and reconstructed facial tissue, volume loss or deflation is not. Therefore, overcorrection of volume is not necessary at the time of original operation, but precise suspension of flap tissue in key regions is critical. Based these observations over 15 years postoperatively, we have modified our technique to include
high lateral suspension of flap volume to recreate the malar eminence, medial periosteal fixation in the periorbital region, and primary blending of the lid-cheek and temporalcheek junction.
159
Versatility of the Radial Forearm Free Flap in Facial Resurfacing
Institution where the work was prepared: New York University Medical Center, New York, NY, USA
Daniel J. Ceradini, MD; Phuong D. Nguyen, MD; Alexes Hazen, MD; Jamie P. Levine, MD; New York University Langone Medical Center
Facial soft tissue defects are a challenging problem with multiple reconstructive options. Free tissue transfer to resurface the face is typically reserved for large
or complex defects, frequently fulfilling a functional purpose in addition to aesthetic goals. Based on skin quality and thickness match, the radial forearm free
flap provides a potentially versatile source of tissue for facial resurfacing. The objective of this study was to determine the patterns of use of the radial forearm
free flap in the community setting for resurfacing facial soft tissue.
We retrospectively reviewed all patients who underwent microsurgical facial resurfacing using the radial forearm free flap at NYU/Bellevue Hospital Center,
New York between 1981-2008. Patient characteristics, etiology of the defect, anatomic location, and surgical course were analyzed.
Thirty three patients underwent thirty four radial forearm free flaps for facial and anterior scalp/forehead resurfacing, with one patient requiring two flaps for
bilateral defects. Compared to our experience prior to 2000 (26% of cases), the radial forearm was used much more frequently after 2000 (74% of cases).
The average patient age was 48 (range 20-93), with 79% male and 21% female. The etiology of defects consisted of soft tissue or skin cancer (68%), trauma
(18%) and sequalae of infection (18%). The most frequent cancer types were squamous cell and basal cell carcinoma. The average radial forearm skin paddle surface area was 66cm2, ranging from 24cm2 to 144cm2. Venous drainage utilized was venae commitantes (74%), the cephalic vein (22%), or both
drainage systems (4%). Location of the defect was varied, often involving multiple aesthetic units including the cheek (33%), nose (26%), forehead/anterior scalp
(19%), perioral area (19%), and chin (11%). The majority of donor sites required skin grafting. Periopertive complications were minor, none of which required
re-operation, and there were no cases of flap loss in this series. Donor site complications were limited to partial loss of the skin graft, all of which healed with
conservative wound care.
Facial resurfacing requires a versatile flap with tissue characteristics similar to the native facial soft tissue. Based on our data from a large hospital center, the
radial forearm free flap has proven to be a versatile flap for facial resurfacing due to the tissue volume, thickness of skin, and pedicle length.
Gastroomental Free Flap Reconstruction of the Head and Neck Neck
Institution where the work was prepared: Virginia Mason Medical Center, Seattle, WA, USA
Stephen Bayles, MD; Virginia Mason medical Center; Richard E. Hayden; Mayo Clinic Arizona
We will present the use of an infrequently utilized tool available to head and neck surgeons in the modern reconstruction era.
Study Design:
Case Series
Methods:
Twenty five gastroomental free flaps were performed. Technical aspects of harvest are reviewed. Advantages and disadvantages of this flap will be described,
as well as illustrative cases displaying this flap’s utility when other donor sites cannot be harvested.
Results:
Flap survival was 96%, with one flap being successfully salvaged after development of a venous thrombosis, and one flap failing as a result of a kink in the
arterial pedicle. Exteriorization of the omentum as an external marker heralded vascular compromise in both cases. Complications included 2 delayed gatric
outlet obstructions, One salivary leak, One delayed abscess and fistula formation 7 months following reconstruction, and one mild superficial bleeding from
the transplanted gastric mucosa.
Conclusions:
The gastroomental flap has proven to be a reliable and valuable tool in head and neck reconstruction, particularly in complex oropharyngeal wounds with
large soft tissue components.
Recipient Vessels Analysis in Free Flap Reconstruction for Head and Neck Cancer
Patients after Radiotherapy
Institution where the work was prepared: Chang Gung Memorial Hospital-Kaohsiung Medical Center,, Kaohsiung, Taiwan
Chien-Chung Chen; Yur-Ren Kuo; Yen-Chou Chen; Yun-Ta Tsai; Pao-Yuan Lin; Seng-Feng Jeng; Chang Gung Memorial Hospital-Kaohsiung Medical Center
Purpose:
Pre-or post operative adjuvant radiotherapy plays an important role in head and neck cancer treatment. Irradiated recipient vessel was still a challenge for mircrovascular free flap reconstruction. Herein, we reviewed our experience in the past five years and analyzed the selection of irradiated recipient vessels and
outcome.
A retrospective reviewed the past five years chart records of the patients with free flap reconstruction after head and neck cancer ablation was done. Total 967
patients had been reviewed, and 69 patients received radiotherapy before free flap reconstruction. 14 patients received preoperative combined radiotherapy
due to advanced carcinoma. 55 patients were recurrent after primary tumor ablation and post-operative adjuvant radiotherapy. Mean age was 54.6 ( 37-75)
years old. All patients received immediate free flap reconstruction post tumor ablation.
Results:
The flaps we most frequently selected for irradiated patients reconstruction were free ALT flaps (38/69), free fibula flaps (17 /69) and free forearm flaps (12
/69). The flap survival rate in irradiation group (n= 69) as compared to the non-irradiation group (n=898) was decreased [89.8% (62/69) versus 95.2%
(855/898), P=0.081]. There were six in seven flaps failure in the irradiation group resulted from the venous insufficiency. The most frequently used recipient
artery and vein in irradiated patients included the superior thyroid artery (56%), facial artery (25%), superficial temporary artery (13%), branches of internal
jugular vein (39%), external jugular vein (25%) and facial vein (23%). Most recipient vessels were ipislateral to the tumor site (62/69). By contrast, the 7 flaps
used the contra-lateral recipient vessels, and all flaps survival finally.
Conclusion:
The previous irradiated or operated neck does not preclude the use of recipient vessels from that side. No significant different of survival rate between the different recipient vessels. Venous insufficiency was the leading reason of vessel compromise after free flap reconstruction in irradiated patients. Choose healthy
and suitable vessel is the key role for the successful head and neck free flap reconstruction.
160
Anatomical Basis and Clinical Application of the Pedicled Thoracoacromial Artery Perforator Flap
Institution where the work was prepared: Shanghai Jiao Tong University, 9th People’s Hospital, Shanghai, China
Yi Xin Zhang, MD1; Yee Siang Ong, MRCS, (Edin)2; Danru Wang1; Jun Yang1; Detlev Erdmann, MD3; L. Scott Levin, MD3; (1)Shanghai 9th People’s
Hospital,Shanghai Jiao Tong University, (2)Singapore General Hospital, (3)Duke University
Background:
Musculocutaneous Perforator flap has the advantage of less donor site morbidity with constant blood supply. The thoracoacromial artery based pectoralis major
muscle flap is a workhorse flap in head and neck reconstruction. However, the anatomical basis on the perforator of the thoracoacromial artery was rarely
described, as well as its clinical application. The purposes of this paper are to depict the cadaver study, surgical techniques, clinical application and further
prospect of the thoracoacromial artery perforator flap( TAAPF ).
Methods:
The thoracoacromial artery perforator flap(TAAPF) were dissected in 12 fresh human cadavers to define the anatomy of the musculocutanous branches of the
thoracoacromial artery and define anatomical landmarks for clinical application. One clinical case with a defect of 11∞~9 cm in anterior neck region after
resection of the larynx cancer, underwent reconstruction with the pedicled TAAPF in 11∞~8 cm. The doner site was closed by direct approximation.
Results:
In all 12 cadavers (24 chest sides), 21/24 (87.5%) present the TAAP coursing through the septum between the clavicular head and sternocoastal heads of pectoralis major muscle. 13/21 present only one musculocutaneous perforator and 8/21 present two musculocutaneous perforators. The caliber of the perforator
varied from 0.4 mm to 1.3 mm, mean 0.8 mm. The vascular supply of TAAPF could reach to the distal of 4th costal rib. The vascular pedicle with a length of
approximately 8cm was obtained down to the subclavian artery, thus, the pedicled flap could be rotated to adjacent region. The typical case healed uneventfully. The donor site morbidity was diminished thus primarily closure and pectoralis major was well preserved. In addition, the recipient site was not bulky with
satisfactory aesthetic outcome.
Conclusions:
The anatomical study of the TAAP provides the basis of clinical application. Although our experience is still limited, the pectoralis major muscle functional preservation and aesthetic outcome indicated that the TAAPF is an option for reconstructing the defect on the region of neck, submental and shoulder or other future
application. Figure legend: Typical Case
Aesthetic Scalp Reconstruction After Large Traumatic Defect; Does the Outcome Justify the Effort?
Institution where the work was prepared: Buncke Clinic, California Pacific Medical Center, San Francisco, CA, USA
Darrell Brooks; Rudolf F. Buntic; The Buncke Clinic, California Pacific Medical Center
Introduction:
Microsurgical tissue transplantation is required for large (>50 cm2) post-traumatic scalp defects with calvarial exposure. Although this provides coverage and
protection of the calvarium, it necessitates that the patient change their style to a “shaved-head” or begin wearing a wig. Expansion of the hair-bearing scalp
can restore a normal hairline and hair orientation. However, expansion around the face is neither comfortable nor concealable. We describe staged aesthetic reconstruction of large post-traumatic defects of the hair-bearing scalp, detail the reconstructive course, and examine the ultimate outcome.
Methods:
This is a retrospective review of large scalp avulsion injuries treated with muscle transplantation acutely and tissue expansion secondarily between 2001-2004.
Inclusion criteria included that the injury be classified as extremely large (>50cm2) as described by Leedy, have exposed calvaria requiring tissue transplantation, and have at least three years follow-up from surgical expansion. Four patients fit inclusion criteria. Age range was 18-35 years. Mechanism of injury
included crush/avulsion in motor vehicle rollover accident (2), and crush/avulsion after a fall from height (2). Two patients initially had less than 50cm2 loss,
but unsuccessful local flap rotation and galeal scoring performed at the referring institutions resulted in the additional loss. The latissimus dorsi muscle flap (3)
and latissimus dorsi muscle combined with the parascapular cutaneous flap (1) were transplanted. The hair bearing scalp (3) and hair bearing scalp and temporal region (1) required reconstruction. Vascular targets were the superficial temporal artery and vein (2) and superficial temporal artery and facial vein (2).
Multiple expanders were placed under the residual scalp after all wounds healed. Patients presented weekly for progressive expansion of their implants. Patients
endured dramatic distortion of their scalps throughout this period.
Results:
All flaps survived with uncomplicated coverage of the calvarium and face. Two expanders were utilized in each case. There was one expander exposure which
occurred near the end of expansion and was treated with removal and flap rotation without event. Duration of expansion was 85-96 days. All reconstructions resulted in restoration of a natural hairline and hair orientation. All patients were extremely satisfied with their result.
Conclusions:
Scalp defects, which are suboptimal candidates for local tissue rearrangement given their size or location, can be successfully managed with tissue transplantation followed by residual scalp expansion. Extremely satisfying results can be obtained. The patient, however, must understand that several surgeries and a
prolonged period of unsightly expansion will be required.
161
Comparison of Scalp and Calvarial Reconstruction with Regard to Flap Type and Recipient Vessels
Institution where the work was prepared: University of California Los Angeles, Los Angeles, CA, USA
Brian P. Dickinson, MD; Jaco Festekjian; Otway Louie; Vishad Nabili; Andrew Da Lio; Keith Blackwell; Peter Ashjian; James Watson; Crisera Christopher;
University of California, Los Angeles
Background:
Microsurgical scalp reconstruction is often used to reconstruct the most difficult defects resulting from tumor extirpation or trauma. Furthermore chronic wounds
or radiation increases the complexity of reconstruction making flap failure disastrous. We present a decision tree for flap reconstruction based on our experience with 68 scalp reconstructions.
Methods:
A retrospective review of a prospectively maintained microsurgical database was conducted of all scalp reconstructions between February 1996 and April
2008 at the University of California Los Angeles Medical Center. Patients were included in the study if they had primary scalp defects resulting from trauma,
intra-cranial tumor extirpation, and primary skin cancers of the scalp or lesions of the auricle with extension onto the scalp. Lesions of the cheek or parotid
gland requiring reconstruction were excluded.
Results:
Between February 1996 and April 2008 68 scalp reconstructions were completed in 67 patients. The mean age of the patients was 65 (range 15-89). The
majority of the patients were male 54/68 (79%). The predominant ASA class was class 3. The majority of flaps were latissimus dorsi free flaps followed by
radial forearm flaps. There was one flap failure (1/68) yielding a success rate of 98.5%. Only one flap required a take back requiring venous anastamosis
revision to an alternate system for an overall takeback rate of 1.5%. Comparing superficial temporal vessels to facial vessels, there was no significant difference in failure rate (1/19) 5% vs. (0/39) 0%, p > 0.05. Vein grafts were used in (2/19) 10% of reconstructions when the superficial temporal vessels were
originally selected. Vein grafting was used in these cases secondary to radiation or trauma making the vessels unusable.
Conclusion:
Scalp reconstructions are challenging and require careful pre-operative planning to ensure success. In our series, the flap failure and take-back rate were low.
While superficial temporal vessels provide inflow and outflow close to the location of reconstruction, alternative operative plans must include knowledge of alternate recipient vessels. Selection of flaps that contain long vascular pedicles allows for use of recipient vessels in the neck without the need to use vein.
The Osteocutaneous Radial Forearm Free Flap: A Novel Implementation for Single Flap Reconstruction of Midface, Upper Lip
Deficiency and Near-Total Nasal Defects
Oren Tepper, MD; Joseph Michaels; Naveen Setty; Jennifer Capla; Nicholas Haddock; Daniel Ceradini; David Hirsch; Jamie Levine; Pierre Saadeh; New
York University Langone Medical Center
Introduction:
Treatment of aggressive nasal squamous cell cancers occasionally leads to total or near-total rhinectomy. Adjuvant radiotherapy further injures local soft tissue
and limits local reconstructive options. Although microvascular flaps (often compound) have been described to reconstruct nasal lining, this case report describes
a novel implementation of an osteocutaneous radial forearm flap to improve maxillary projection, restore full-thickness upper lip height, reconstruct the nasal
vestibules, and provide nasal lining for near-total nasal reconstruction in a single flap.
Methods:
A 54-year-old man presented five years after undergoing near-total rhinectomy and radiotherapy for recurrent nasal squamous cell carcinoma. In addition to
his nasal defect, the patient demonstrated significant loss of midface projection and foreshortening of his upper lip. The first stage involved the simple delay of
forearm skin into two adjacent partial rectangles. In the second stage, ulnar skin paddles were fashioned to recreate the nasal vestibules. The exposed surfaces
were skin grafted. The third stage involved transfer of the prefabricated flap which included 10 cm of 25% thick radius to augment maxillary projection and to
minimize the chance of fracture. The pyriform aperture was opened and the contracted upper lip was released to recreate the original defect and restore upper
lip anatomy. The radius was fixed to the maxilla to improve projection and the flap was revascularized to facial vessels. The anterior half of the flap was used
to restore lip height both externally and at the gingivobuccal interface, while a deepithelialzed portion provided further maxillary augmentation. The posterior
vestibular portion was inset into the pyriform aperture. Four weeks later, support was restored using iliac bone graft and conchal cartilage grafts and coverage was achieved with a paramedian forehead flap. Flap division and minor refinements were performed at later intervals.
Results:
Nine months postoperatively the patient demonstrated excellent nasal form, patent nasal airways, improved midface projection, and improved upper lip height.
Complications were limited to prolonged healing of surrounding radiated skin.
Conclusions:
This case report demonstrates the novel use of a prefabricated osteocutanoeous radial forearm free flap to provide stable midface support, upper lip height
correction, and nasal lining as the foundation for near-total nasal reconstruction. Accurate design, careful planning, and up-front delay maximize the versatility and reliability of this flap.
162
The Fate of Different Reconstructive Modes for Mandibular Ameloblastomas
Institution where the work was prepared: National Taiwan University Hospital, Taipei, Taiwan
Shih-Heng Chen1; Yueh-Bih Tang Chen, Ph, D1; Jung-Hsien Hsieh1; Hung-Chi Chen, MD, FACS2; (1)National Taiwan University Hospital, (2)E-da/I-I Shou
University Hospital
Mandibular ameloblastomas are not infrequently seen. However, most of the patients were primarily treated by oral surgeons, ENT surgeons or surgeons who
were not comfortable with vascularized bone transfers. Therfore, many patients were left with formidable complications as malocclusion, deviation of chin,
facial deformity, chronic intraoral/ extraoral drainage, extrusion and infection of dead bone, soft tissue wasting or even ultimate extrusion of the implant.
In 15 years, 57 patients were referred to us for management of the aforementioned problems, only 9 patients with mandibular ameloblastoma were treated
primarily by the plastic surgeons. In 57 patients, 21 were reconstructed with nonvascularized bone, 10 of them were complicated with chronic drainage, and
11 of them were complicated with remarkable facial deformity. Thirty six out of the 57 patients were reconstructed with reconstruction plate without incorporation of bone. Ten patients were referred for progressive soft tissue wasting, 32 were referred for overt facial deformity, and 15 of them were referred for extrusion of the implant. The 9 patients treated primarily by the plastic surgeons all obtained satisfactory long term result.
The complicated cases were then reconstructed with vascularized iliac bone in 44 patients, vascularized fibula in 13 patients. The presenting symptoms are
deformation and loosening of plates, soft tissue wasting, end up with chronic drainage and ultimately extrusion of the plates. Problems and difficulties of
Reconstructions with Implant Failures were: 1) scarring and capsule formation around implants. 2) difficulty in dissecting and approaching the glenoid fossa.
3) lack of a clear plane to expand the pocket to accommodate a vascularized bone camouflaged ascending ramus. 4) possibility of facial nerve injury or traction during dissection or expansion. 5) placement of incision should be carefully designed since there had been soft tissue atrophy and thinning of skin.
Conclusions:
Secondary mandibular reconstruction after implant failure may cause facial nerve injury or difficulty in approaching the glenoid fossa. Fascia lata sling operation is always required in hemimandibular reconstruction in patients with implant failures. Use of mandibular implants as a reconstruction tool should be limited. It is advised that vascularized bone is always the material of choice in major mandibular reconstructions.
The DIEP Flap for Reconstruction of Total Laryngo-Pharyngeal Defects
Institution where the work was prepared: Harbor-UCLA, Torrance, CA, USA
Otway Louie, MD; Brian Dickinson; Jay Granzow; Brian Boyd; UCLA Medical Center
Background:
Total laryngo-pharyngectomy reconstruction with microvascular free flaps remains challenging. Current methods of reconstruction include anterolateral thigh,
radial forearm, and jejunal flaps, all of which have substantial donor site morbidity. Ideal flaps should possess a long`pedicle length, as well as good caliber
donor vessels. We present a novel approach for total laryngo-pharyngectomy reconstruction using deep inferior epigastric perforator flaps.
Method:
A retrospective review of head and neck reconstruction cases performed at Harbor-UCLA from 2006-2007 was performed. Those undergoing DIEP flaps were
identified; management and post-operative course were analyzed.
Results:
2 patients underwent successful reconstruction of total laryngo-pharyngectomy defects using DIEP flaps. Both patients had recurrent laryngeal cancer after failed
radiation therapy. Flaps up to 10x30 cm were harvested. In each case, 3 lateral-row perforators were used. Average donor vessel diameters were 2.5 cm and
3.0 cm for the artery and vein, respectively. The abdominal wounds were closed primarily. Flap survival was 100% with no emergent re-explorations. Average
length of stay was 11 days. There were no post-operative bulges or hernias. A routine post-operative swallow study performed in one patient demonstrated
no evidence of leak.
Conclusion:
The DIEP flap is a useful addition to the armamentarium for reconstruction of total laryngo-pharyngectomy defects. Pedicle length is abundant, with excellent
caliber donor vessels. Large surface-area flaps can be harvested; excess flap not used for laryngo-pharyngeal reconstruction can be de-epithelialized or utilized for external skin. Primary closure of the donor site is possible, negating the need for skin grafts.
163
ASRM - Clinical Breast
Achieving Symmetry in Perforator Flap Breast Surgery
Suhail Kanchwala, MD1; Reza Miraliakbari, MD2; Joseph Serletti1; (1)University of Pennsylvania, (2)Penn State College of Medicine
Background:
Advances in breast reconstruction techniques in the last decade have led to an increase in aesthetic expectations by both surgeons and patients. The modern breast
reconstruction must achieve adequate size, projection, and ptosis to match the contralateral breast. Despite its importance, there remains a paucity of literature on the
incidence of symmetry procedures in breast reconstruction. In addition, there are no current reports on the rates of symmetry operations performed after perforator
flap breast reconstruction. The purpose of this study is to critically evaluate the number and type of symmetry procedures performed in perforator flap breast surgery.
Methods:
A single surgeon retrospective review of all patients who presented for autologous breast reconstruction between 2005-2007 was performed. Study patients were identified on the basis of CPT codes for symmetry procedures (i.e. revision of reconstructed breast, contralateral mastopexy). Symmetry procedures were grouped into six
categories: major revision (recreating IMC), minor revision (skin/fat excision), mastopexy, reduction, liposuction, and fat grafting. Data regarding demographic and
patient variables such as risk factors and complications were recorded. Statistical analysis was performed on frequency tables using a chi squared test of significance.
Results:
250 patients (360 flaps) underwent free flap breast reconstruction during the study period. Of this group, 80 patients (110 flaps) underwent further surgery to achieve
symmetry (33%). An equal number of free TRAM and DIEP/SIEA flaps were performed in this group. The average age of the study group was 51 years with a mean
follow-up of 17months. Contrary to previous studies, we found that more contralateral procedures were performed overall (primarily reduction and mastopexy). There
was no statistically significant difference between the free TRAM and DIEP/SIEA groups in either number or type of symmetry procedure performed. Obesity (BMI>30)
resulted in a statistically significant increase in the number of symmetry procedures performed. Nevertheless, no other patient variables impacted the overall incidence
of symmetry procedures. In addition, we found that post-operative radiation therapy did not increase the incidence of symmetry procedures.
Conclusion:
The incidence of symmetry procedures in perforator flap surgery has not been previously studied. Our results demonstrate the following: 1. More symmetry
procedures are performed on the contralateral breast rather than the ipsilateral breast. 2. Risk Factors (i.e. XRT, Smoking) do not increase the incidence of symmetry procedures. 3. Contralateral mastopexy/reduction can be safely performed at the time of immediate reconstruction 4. Perforator flap surgery does not
impact the incidence of symmetry procedures.
New Microsurgical Breast Reconstruction using the Posterior Medial Thigh ( PMT ) Perforator flap
Institution where the work was prepared: Yokohama City University Medical Center, Yokohama, Japan
Toshihiko Satake, MD1; Takashi Ishikawa, MD1; Jiro Maegawa, MD2; Soko Watanabe, MD1; Takeshi Nishikori, MD1; Seiko Ko, MD1; Tomohiro Imai,
MD1; Tomoko Takano, MD3; (1)Yokohama City University Medical Center, (2)Yokohama City University Hospital, (3)Kitasato Institute Hospital
Background:
A perforator flap from the posterior and medial thigh aspects based on the profunda femoris vessels can provide a small or moderate amount of skin and adipose tissue for safe autologous breast reconstruction , since musculocutaneous or septocutaneous perforators in its origin from the adductor magnus and semimembranosus muscles are consistently large enough in caliber to establish larger skin flaps than the gracilis muscle perforators.
Methods:
Between January in 2006 and May in 2008, 10 women underwent breast reconstruction using the Posterior Medial Thigh ( PMT ) perforator flaps. The patients’
ages ranged from 35 from 48 years ( median, 41 year ). All patients were non-delivered. There were four immediate breast reconstructions after nipple-sparing or skin-sparing mastectomy, and six cases were secondary reconstructions. Mean follow-up period of the 10 patients was 12 months(range, 3 to 23 months).
The mean weight of the flap was 246g. Skin islands were designed from medial to posterior proximal third of the thigh transversely including underlying adipose tissue ranging from 8.5?17.5 cm to 14.0?28.0cm in size.
Results:
The location of the perforators was examined intraoperatively, in most common cases they were located 8 cm below inguinal and buttock crease. In eight cases
one perforator could be identified and in two cases two perforators could be detected. About half of these perforators passed through the fascia and then
coursed between the adductor magnus and the semimembranous muscle, soon turned into the semimembranous muscle. The others run into the adductor magnus or the semimembranous muscle directly. On one patient the flap was transferred with the SCIP flap in a chimera style. All flaps totally survived and there
was no functional donor site morbidity caused by flap harvesting.
Conclusions:
The PMT perforator flap resembles to the gracilis flap, in that it may allow a two-team approach and no change in the patient position intraoperatively. Compared to
the gracilis flap, the advantages of the PMT perforator flap are (1) less conspicuous donor site scarring, (2) smaller risk of lymphedema, and (3) ample amount of
transferrable adipose tissue. On the other hands, the disadvantages are (1) the dark skin color of the proximal thigh, and (2) limitation of flap width in a case of a
lean patient. We conclude the PMT perforator flap allows reliable, aesthetic breast reconstruction without significant donor site morbidity.
164
Impending Vascular Compromise of Mastectomy Skin Flaps: a Salvage Option Using a Non De-epithelialized Buried Flap
Institution where the work was prepared: Tel Aviv Medical Center, Tel Aviv, Israel
Yoav Barnea; Shy Stahl; Aharon Amir; Arik Zaretski; Ehud Miller; Jerry Weiss; Schlomo Schneebaum; Eyal Gur; Sackler Faculty of Medicine, Tel-Aviv
University
Skin-sparing mastectomy (SSM) has emerged over the past decade as the optimal approach for patients with early-stage breast cancer who desire immediate
postoperative breast reconstruction. The SSM technique has the benefits of preserving the infra-mammary fold, improve the shaping of the breast mound, retaining the sensitivity of the skin envelope, and using breast skin in the final reconstruction. These characteristics have improved the results of immediate breast
reconstruction, achieving an aesthetically long lasting reconstructed breast. One major complication in SSM is native breast skin flap necrosis. Previous publications reported an incidence of SSM flap complications ranging from 3.6% 21.6%, with a higher incidence in patients with diabetes, a history of breast radiation, an increased body mass index, and active smoking. Partial or full-thickness loss of SSM flaps may complicate wound healing and even compromise the
success of the reconstruction. Furthermore, SSM flap complications may delay the initiation of adjuvant therapies, such as chemotherapy and radiotherapy, and
potentially compromise their delivery.
We describe a patient who underwent SSM and immediate reconstruction with a superficial inferior epigastric artery (SIEA) free flap procedure. Intraoperatively,
the native breast skin flaps showed compromised vascularity with impending necrosis and no clear demarcation line. We have chosen to salvage the reconstructed breast by burying the non de-epithelialized SIEA flap under the native breast skin flaps until clear demarcation of necrosis was evident. In a second procedure,
all necrotic skin was debrided, and the defect was reconstructed with skin from the SIEA flap, that was lying underneath the necrotic tissue for five days.
We concluded that this technique allows maximal preservation of native breast skin, sparing the need for skin grafting the debrided native skin areas, thereby
providing an aesthetically superior result.
Use of the Posterior Hip Perforator flap for Microsurgical Breast Reconstruction
Institution where the work was prepared: Center for Restorative Breast Surgery, New Orleans, LA, USA
Scott Keith Sullivan, MD, FACS; Frank J. DellaCroce; Chris Trahan; Center for Restorative Breast Surgery
Background:
Microsurgical breast reconstruction in the lean patient has always been most difficult. Acquiring adequate fat volumes is always a challenge, and then dealing
with the associated donor deformities can sometimes detract from the overall outcome. Historically those patients which have inadequate abdominal fat would
then be offered gluteal perforator reconstructions. Many of these patients anatomically lack excess volume and projection in the buttock so harvest of tissue in
this region can sometimes create a deformity that is difficult to correct. We began to examine the use of the Posterior Hip Perforator flap in these instances. This
is an allocation of fat that should be eliminated in all cases aesthetically, in doing so it provides better shape to the waist and projection to the behind, thus providing a complimentary donor deformity. The vascular anatomy is not constant, like the DIEP or GAP flaps but there are a variety of adequate vessels (lumbar
perforator, superior gluteal perforator, circumflex iliac) to choose from though the arterial caliber typically ranges from 1-1.75mm.
Methods:
Since the beginning of 2008, 7 patients have been selected for posterior hip perforator flap breast reconstructions. 6 patients underwent bilateral mastectomies
with immediate reconstruction, 1 patient had delayed unilateral breast reconstruction with chimeric bilateral posterior hip perforator flaps. The 6 immediate
patients are very lean with average gluteal fat and projection. The unilateral delayed is a patient with average body build, whom already had a contralateral
breast reconstruction with a TRAM and later diagnosed with new advanced disease in the remaining breast.
Results:
Average reconstructive operative time of 6 ? hours was similar to that of bilateral GAP reconstructions. Of the 14 posterior hip perforator flaps, 7 were superior gluteal, 5 lumbar and 2 circumflex iliac in origin. 100% overall flap survival. One patient returned to the operating room shortly after completion for reexploration, she required repositioning of the implantable doppler wire and pedicle which had kinked. Aesthetic outcome of the breast reconstruction is equal
to that of other perforator flap reconstructions. The donor site result was found to be far superior to S/I-GAP deformities in patients of similar body habitus.
Conclusion:
Posterior Hip Perforator flaps are a superior alternative to traditional GAP flap reconstructions in the thin patient. Though the perforator dissection may be a
little more difficult than the GAP, the corresponding donor site is far superior aesthetic result.
The Incidence and Perioperative Factors of Pulmonary Embolism in Breast Reconstruction Patients
Institution where the work was prepared: University of Manitoba, Winnipeg, MB, Canada
Jennifer Lindsay Giuffre, MD; Edward W. Buchel; Thomas E.J. Hayakawa; University of Manitoba
Purpose:
Pulmonary embolism (PE) is a known complication of breast reconstruction using free tissue transfer. There is no literature outlining the incidence and consequences in this group of patients. We identify the incidence of PE; outline the perioperative risk factors, and evaluate the outcomes based on our centers 4 year
experience.
Methods:
All patients undergoing free flap breast reconstruction in between 2004-2008 were retrospectively reviewed. A total of 484 patients underwent microvascular
breast reconstruction. Patient demographics, comorbidities, diagnosis, type of flap, presenting symptoms, imaging, treatment and complications were recorded.
Results:
The incidence of PE was 12/484(2.5%). No patient had a previous venous thromboembolic event (VTE). Patients presented 3-20 days postoperatively with
decreased oxygen saturations, tachypnea, shortness of breath and tachycardia. The diagnosis was confirmed with CT scan. The standard perioperative management consisted of preoperative placement of sequential compression devices and TED stockings continued until the third postoperative day, with mobilization beginning on the second postoperative day. There was no routine administration of perioperative anticoagulant medications. Toradol was routinely administered for its analgesic effects for 72 hours following operation. Patients with radiographically confirmed PE were treated with Intravenous Heparin and discharged on Dalteparin or Coumadin. One massive PE resulted in a fatality. All other patients recovered uneventfully.
Conclusion:
We report a 2.5% incidence of PE in patients undergoing free flap breast reconstruction. This group is a high risk group given the lengthy surgical times, immobility and a history of malignancy. At our center, concerns regarding increased bleeding making perforator dissection difficult have prevented the routine use
of perioperative anticoagulants for DVT prophylaxis. The results of this study indicate that this needs to be re-evaluated.
165
1000 Consecutive Venous Anastomoses Using the Microvascular Anastomotic Coupler in Breast Reconstruction
Institution where the work was prepared: University of Pennsylvania Health System, Philadelphia, PA, USA
Shareef Jandali, MD1; Stephen J. Kovach1; Liza C. Wu1; Stephen J. Vega2; Joseph M. Serletti1; (1)University of Pennsylvania Health System, (2)University
of Rochester Medical Center
Purpose:
To examine the effectiveness of the microvascular coupler and the rate of thrombosis with its use for venous anastomoses in microsurgical breast reconstruction.
Methods:
A retrospective review of operative reports and patient records from July 2002 to May 2008 was performed. The setting was two major teaching medical centers. Follow-up ranged from one month to five years. Data was obtained on the rate of venous thrombosis.
Results:
A total of 1000 venous anastomoses were performed using the coupler. This included 464 cases of unilateral breast reconstruction and 268 cases of bilateral
breast reconstruction. All anastomoses were performed in an end-to-end fashion. There was a total of five instances of venous thrombosis (5/1000) giving a
rate of thrombosis for coupled anastomoses of 0.5 %.
Conclusions:
The patency rate for venous anastomoses performed with the microvascular coupler is excellent when compared to standard suture techniques. The coupler is a safe, effective, and expedient method for venous anastomoses. It minimizes flap ischemic time, reduces reperfusion injury, is easier on the surgical team, and saves costly OR time.
CT Angiography in Planning Abdomen-based Microsurgical Breast Reconstruction: A Comparison to Duplex Ultrasound
Jeffrey R. Scott, MD; Daniel Liu; Hakim K. Said, MD; Peter C. Neligan; David W. Mathes; University of Washington
Background:
In order to plan abdominal perforator-based microsurgical breast reconstruction, duplex ultrasound is often employed to pre-operatively identify abdominal
wall blood vessel location. Recently, several groups have begun to favor computed tomography angiography (CTA) in place of duplex ultrasound for their preoperative planning. It is unknown whether the identification of abdominal wall perforators is enhanced with CTA. The purpose of this study is to identify whether
clinically useful perforating vessels found on CTA correspond with perforating vessels found on duplex ultrasound.
Methods:
A prospective study of 23 consecutive patients undergoing 30 abdomen-based microsurgical breast reconstruction from August 2007-April 2008 with both
preoperative CTA and duplex ultrasound studies. Median age was 51 years (+/-5.6). Thirty breast reconstructions were performed, including 4 muscle-sparing TRAM, 8 superficial inferior epigastric artery, and 18 deep inferior epigastric perforator reconstructions. Perforator size and location were determined by
both CTA and ultrasound data. The two largest perforators were chosen per abdominal side for comparison between studies. In addition, the locations of the
pre-operatively identified perforators by both techniques were confirmed in the operating room.
Results:
CT Angiography pre-operatively identified 83 of the largest perforators. Fifty-five of these large perforators (66%) were identified on ultrasound. The remaining 28 perforators (33%) were not identified by ultrasound. The presence of perforators missed on ultrasound but identified on CTA was confirmed at the time
of operation. No superficial inferior epigastric arteries were identified by ultrasound. Of the 8 reconstructions with the superficial inferior epigastric system, all
8 superficial inferior epigastric arteries were identified preoperatively as adequate size for microsurgical transfers by the surgeon or radiologist, with an average diameter of 1.6 millimeters on CTA. One of eight SIEA flaps failed (12.5%), while the remainder was successful (87.5%).
Conclusions:
There are many distinct advantages to the use of preoperative CT angiography for planning abdominal perforator-based microsurgical breast reconstruction,
including reliable and accurate identification of the superficial inferior epigastric artery. In addition, duplex ultrasound failed to identify 33% of the largest perforators in the deep inferior epigastric system. This study demonstrates the superiority of CT angiography over duplex ultrasound as a tool for pre-operative
planning of perforator based breast reconstruction.
Introducing the Sc-GAP (Septocutaneous Gluteal Artery Perforator Flap)
Institution where the work was prepared: MUMC+ Masstricht University Medical Centre, Maastricht, Netherlands
Stefania Tuinder, MD1; Arno Lataster1; Tim Leiner, MD1; Marga F. Massey, MD2; Robert J. Allen, MD3; Rene Van der Hulst, MD, PhD4; (1)MUMC+
Maastricht University Medical Centre, (2)The Center for Microsurgical Breast Reconstruction, (3)Louisiana State University, (4)University of Maastricht
The s-gap flap is used for breast reconstruction sinds 1995: usually its perforators have to be dissected through the gluteus maximus muscle. The dissection may
be difficult. To look for an alternative based on septocutaneous perforators, we performed an anatomical study to evaluate the presence and suitability of these
perforators in the gluteal area running between the gluteus maximus and medius muscle. After having found these perforators the first clinical cases of unilateral breast reconstruction with an sc-GAP (septocutaneous gluteal artery perforator flap) were performed.
Anatomical Study:
Formalin fixed cadavers of three adults were used to study the anatomy in 6 gluteal regions.
In every corpse at least 1 septocutaneous perforator passing between the gluteus maximus and medius muscle was found (range number; 0-2 for the left and
1-4 for the right side). All perforators originated from the superior gluteal artery.
Clinical Cases:
First case: A 56 year-old female, diagnosed with an invasive left breast cancer treated by lumpectomy with postoperative external beam radiation. 14 years
later she elected to proceed with a radical mastectomy in relation with an ipsilateral breast cancer. She had a low transverse abdominal wall incision for a
reported hysterectomy, and a preoperative MRA revealed bilateral deep inferior epigastric artery and vein occlusion but three septocutaneous perforators
between the gluteus maximus and medius muscles bilaterally.
Second patient: a 44-year old female diagnosed with an invasive left breast cancer treated by mastectomy with postoperative external beam radiation. the BMI
was 18.
A preopearative MRA revealed two septocutaneos perforators between the gluteus maximus and medius muscles bilaterally.
Preoperative markings for a sc-GAP flap consisted of a skin island centered on one perforator within the ipsilateral gluteal region with the marks above the
margin of the gluteus maximus muscle. This design is more cephalad than a conventional S-GAP flap.
The sc-GAP is technically much easier, and can be performed more quickly than the conventional S-GAP. An additional advantage is the number of laterally
orientated septal perforators which provide a long pedicle.
166
Acquiring maximum volume autogenous breast reconstruction with stacked/chimeric DIEP and Posterior Hip Perforator flaps
Institution where the work was prepared: Center for Restorative Breast Surgery, New Orleans, LA, USA
Scott Keith Sullivan, MD, FACS; Frank J. DellaCroce, MD, FACS; Chris Trahan; Center for Restorative Breast Surgery
Background:
Maximizing the volume of the reconstructive breast can sometimes be quite challenging. Over aggressive tissue harvest can often leave a less than desirable
donor site result. In those patients with average or lighter frames this donor disfigurement can be impossible to correct. In these patients we have found the ability to maximize the reconstructive volumes by being slightly less aggressive in tissue harvest from two sites (abdomen and posterior hip) and combining the two
for chimeric perforator flap breast reconstruction.
Methods:
Patient selection for chimeric DIEP/Posterior hip perforator flap breast reconstruction were those whom had inadequate abdominal or gluteal fat alone to create the
volume breast they desire, or those patients whom would suffer irreparable gluteal disfigurement if this tissue alone was used to create the desired breast size.
Results:
Since the beginning of 2008 twelve patients have undergone bilateral breast reconstruction with chimeric DIEP/Posterior Hip Perforator flaps. The composition
of the breast reconstructions were 11 immediate, 7 delayed and 6 explantations. Average reconstructive operative times of 7 ? hours. Two patients required
re-operation, one for postoperative hemorrhage from the mastectomy, the second re-explored for arterial vascular compromise. All re-explorations were successful, as well as all flap survival.
Conclusion:
Chimeric perforator flap breast reconstructions have afforded us the opportunity to obtain maximum tissue volume for the reconstructed breasts, while at the
same time diminishing the adverse consequence of tissue harvest to the donor sites. The variability of vascularity to the Posterior Hip Perforator flap can provide some challenges, however the pedicle size is adequate for branch chain revascularization to a branch of the DIEP flap.
The Transverse Upper Gracilis Flap as an Alternative to Abdominal Tissue Reconstruction: Technique and Modifications
Institution where the work was prepared: California Pacific Medical Center, San Francisco, CA, USA
Karen M. Horton, MD, MSc, FRCSC; Rudolf F. Buntic, MD; Darrell Brooks, MD; Matthew Trovato; California Pacific Medical Center
Introduction:
Inner thigh skin and fat based on the transverse upper gracilis (TUG) flap blood supply provides an autologous donor area with qualities favorable to microvascular breast reconstruction. We will describe our experience with the TUG flap for immediate and delayed microsurgical breast reconstruction, our surgical
technique for intraoperative shaping of the breast mound, and the potential for immediate nipple and areolar complex (NAC) reconstruction.
Methods:
The flap is designed with a semi-lunar skin paddle centered over the longitudinal axis of the gracilis muscle in the inner thigh. Following pedicle division,
absorbable sutures are used to cone the flap to achieve greater projection (Figure 1). Interrupted horizontal mattress sutures are used to accentuate the standing cone of the flap and construct a nipple prominence, while the naturally darker pigmented inner thigh skin creates an areolar reconstruction. RESULTS: From
2004 to 2008, 35 inner thigh flaps were performed after mastectomy in both delayed and immediate settings. Patient age averaged 49 years (range 32 to
64 years). Six patients had previous radiation. Flap dimensions extended up to 28 cm long by up to 11 cm wide. All flaps survived without any soft tissue loss
or fat necrosis. Complications were a single take-back for venous thrombosis with complete flap salvage, donor area skin breakdown in 8 flaps, and 5 donor
site seromas. There was no functional loss at the donor area and all patients resumed normal activity.
Discussion:
TUG flap dissection is relatively straightforward, reliable and can be aesthetically superior to abdominal reconstruction in that: (1) it allows for immediate NAC
reconstruction, negating the need for secondary surgery and (2) coning of the flap creates excellent projection of the reconstructed breast. Unlike abdominal
flaps, loss of the gracilis muscle is not associated with the risk of abdominal hernias, bulging or functional donor site complications. The greatest drawback of
the inner thigh flap is the inner thigh scar; yet its location near the groin crease is readily concealable in all clothing except swim suits or underwear.
Conclusion:
Candidates for TUG flap breast reconstruction include patients desiring autologous tissue reconstruction with sufficient superomedial thigh tissue, those with previous
harvest of abdominal tissue or thin or athletic patients without sufficient abdominal donor sites or who do not desire abdominal scars. The TUG flap provides excellent projection and volume that often matches the original breast. Donor site morbidity is minimal, without functional consequences from gracilis muscle harvest.
167
Septocutaneous Deep Inferior Epigastric Artery Flap for Breast Reconstruction
Mary Lester, MD; Robert J Allen; Maria M. LoTempio; Medical University of South Carolina
Introduction:
The lower abdominal tissue continues to be the most ideal donor site for autologous breast reconstruction. The advent of preoperative imaging increases our
ability to seek the most advantageous abdominal perforator present. Septocutaneous perforators when present are often large perforators that offer multiple
advantages to both the surgeon and patient.
Methods:
All patients receiving evaluation for abdominal perforator flaps underwent preoperative imaging with MRA and CTA of the lower abdomen beginning in January
2008. The imaging studies were reviewed by the plastic surgery team. Each perforator was mapped on an x-y axis with the umbilicus as a reference and graded as small, medium or large in size. A detailed operative plan was created prior to marking the patient.
Results:
Forty-five abdominal flaps have been examined to date. Ten flap patients were identified as having a Septocutaneous Deep Inferior Epigastric Artery Perforator (SCDIEP). 60% of the patients were undergoing bilateral reconstruction for stage III carcinoma with a combined prophylactic mastectomy. 30% of the SC-DIEPs were
located at or cranial to the umbilicus, and were categorized as large. Intraoperatively the septocutaneous perforators were located as mapped by preoperatively
and each flap was executed according to plan. The average operative time for a bilateral reconstruction was five hours and fifty-eight minutes. This is a decrease
of eighty minutes compared with our pre-imaging experience. There were no flap losses, and only one patient with clinically significant fat necrosis.
Conclusions:
Preoperative imaging allows a thorough exam of the DIEA perforators. In our small sample size, SC-DIEPs were found in approximately 20% of the flaps
imaged. When present SC-DIEPs are typically single large terminal branches, and are adequate perfusion for a hemiabdomen. Septocutaneous perforators
eliminate the intramuscular dissection of the DIEP which significantly lessens the degree of difficulty. The avoidance of intramuscular dissection also decreases
donor site morbidity by ensuring the rectus muscle will remain innervated as the intercostal nerves enter the rectus sheath laterally. Although they are not universally present and can be present cranial to umbilicus, SC-DIEPs offer advantages that warrant imaging to detect their presence when evaluating the abdomen
for breast reconstruction. We believe the benefits of SC-DIEPs include large vessels, ease of dissection, decreased donor site morbidity, and shortened operative time. The SC-DIEP has become our first choice for breast reconstruction.
Figure 1: CTA of SC-DIEPs.
Figure 2: Map of SC-DIEPs (Umbilicus is 0, right is negative and caudal is negative).
Lymph Node Transplantation in Breast Reconstruction using Perforator Flaps
Maria M. LoTempio1; Mary E. Lester1; Julie Vasile2; Marga F Massey1; Josh L. Levine3; Heather Erhard4; David Greenspun4; Robert J Allen1; (1)Medical
University of South Carolina, (2)None, (3)ALbert Einstein, (4)Albert Einstein
Introduction:
For many women undergoing breast reconstruction, the negative impact of upper extremity lymphedema outweighs the benefits of breast reconstruction. Patients
with lymphedema present a challenging problem, and typically is not addressed during the reconstruction process. Lymph node dissections have decreased
secondary due to the advent of the sentinel node biopsy. However, 7% of patients undergoing sentinel lymph node biopsy develop lymphedema. Previous treatments options have not proved to be highly successful, and include lymphatic massage and lymphaovenous anastomosis. We introduce a combined treatment
for breast reconstruction using deep inferior epigastric perforator flap (DIEP) along with lymph node transplantation for lymphedema.
Methods:
Beginning in 2007, five patients have undergone bilateral breast reconstruction using the DIEP along with simultaneous lymph node transplantation. Each
patient had demonstrated upper extremity lymphedema by measurements and subjective findings. Of the five patients four had radiation therapy and five had
sentinel node dissection. The lymph node flap was harvested surrounding the superficial circumflex vessels in conjunction with the DIEP. The combined DIEP and
lymph nodes were anastomosed to the internal mammary artery. Preparation of the axilla included removal of scar tissue, and fixation of the lymph nodes into
the axilla.
Results:
Each patient had an uncomplicated postoperative course. These patients started to experience resolutions of lymphedema as early as ten days after surgery
and continue up to six months. Currently, four patients no longer need lymphatic massage nor wear an arm compression garment. One patient had a recurrence of breast cancer. Each patient reported their arm circumference had improved and decreased morbidity associated with lymphedema.
Conclusion:
Lymph node transplantation is a relatively new and exciting option for the management of lymphedema. Women who undergo breast reconstruction using perforator flaps can have simultaneous lymph node transplantation with minimal morbidity. These patients experienced a continued improvement and five patients
experienced 75% resolution of symptoms.
168
ASRM Clinical: Head and Neck III
The “Omega-shaped” Fibula Osteocutaneous Free Flap for Reconstruction of Extensive Mid-facial Defects
Institution where the work was prepared: The University of Texas M. D. Anderson Cancer Center, Houston, TX, USA
Matthew M. Hanasono, MD; Roman J. Skoracki; The University of Texas M. D. Anderson Cancer Center
Background:
Reconstruction of extensive palatomaxillary defects is among the most challenging surgeries to perform in the head and neck. Of particular difficulty is functional restoration of the complex three-dimensional form of the mid-face with bone and soft tissue flaps that do not inherently resemble the shape of the native
maxillae.
Methods:
Between 2004 and 2008, we performed 17 reconstructions for extensive mid-facial defects after oncologic resection. Fourteen of these reconstructions were
for bilateral maxillary defects and 3 were for unilateral defects. Patients ranged in age from 14 to 72 (mean=54 years). Nine reconstructions were performed
at the time of mid-facial resection and 8 were delayed. Ten patients received preoperative or postoperative radiotherapy.
Results:
Bilateral defects were reconstructed with a fibula osteocutaneous free flap shaped using four closing wedge osteotomies to resemble the Greek letter “omega”
in the transverse plane (Figures 1 and 2). Unilateral defects were reconstructed with 2 wedge osteotomies to resemble half an “omega.” The skin paddle was
used to resurface the oral cavity. Three of these flaps included soleus or flexor hallucis longus muscle to obliterate the maxillary sinus. In addition, 3 anterolateral thigh free flaps and 1 serratus muscle with rib free flap were used to provide additional tissue for cheek or orbital floor reconstruction. There were no flap
losses. Complications included: infection, hematoma, plate exposure, and donor site skin graft loss (1 occurrence of each). All patients regained normal speech
after surgery. Postoperatively, 6 patients consume a regular diet, 8 patients consume a soft diet, and 3 patients consume a pureed or liquid diet (preoperatively, 10 patients had a regular diet, 6 patients had a soft diet, and 1 patient was tube feed dependent). Six patients underwent dental restoration using osseointegrated implants after reconstruction and 7 patients are awaiting implant placement.
Conclusions:
We present a technique for shaping the fibula osteocutaneous free flap to mimic the configuration of the mid-face. This technique restores mid-facial height and
width, isolates the oral cavity from the sinonasal cavities, and can accommodate osseointegrated implants for dental restoration.
Restoring the Failed Cranioplasty: Non-Anatomic Titanium Mesh with Perforator Flap
Institution where the work was prepared: Shock Trauma-Johns Hopkins Medical Center, Baltimore, MD, USA
Hugo St-Hilaire, MD, DDS1; Suhail K. Mithani, MD1; Eduardo Rodriguez, MD, DDS2; (1)R Adams Cowley Shock Trauma Center, (2)R. Adams Cowley
Shock Trauma Center
Introduction:
Composite cranial vault restoration aims to protect the brain and restore cranial form. Local and systemic factors such as malnutrition, extensive zone of injury
from radiation therapy or multiple surgical explorations play a pivotal role and complicate routine options. We are presenting our philosophy in the management of the failed cranioplasty with local soft tissue deficit using perforator based flaps in addition to a non-anatomic titanium mesh cranioplasty.
A retrospective review of patients who underwent secondary cranioplasty using non-anatomic titanium mesh cranioplasty and perforator free flap reconstruction was conducted 2002 to 2008. Data collected included age, gender, type and size of defect, reconstructive procedures, outcome and length of follow up.
Results:
Ten patients who underwent revision of failed cranioplasty with a combination of perforator flap and titanium mesh cranioplasty were identified. There were
eight males and two females with a mean age of 48.5 years old. The initiating events included trauma and craniotomy, two of which underwent radiation therapy. The average calvarial defect was 175.6 cm2 while the average flap size was 266.2 cm2. Eight anterolateral thigh flaps, one deep inferior epigastric
artery perforator flap and one ulnar artery flap were used in this series. There were no flap losses but one major and two minor complications. The mean follow-up was 13.8 months.
Discussion:
Titanium is light, strong, biocompatible and performs well in the face of contamination and exposure. It is easy to contour and fixate. Being an alloplast, the
stability of the reconstruction is entirely dependent on the quality of the soft tissue envelope. Free muscle flaps have been used extensively in cranial vault reconstruction. However, long term flap atrophy has led to an interest in adipocutaneous perforator free flaps. The combination of titanium mesh cranioplasty and
adipocutaneous free tissue transfer has resulted in reliable and aesthetic reconstructions. All of the reconstructions have preserved their volume to date. The
durable nature of adipocutaneous free flaps allows immediate contouring with the knowledge that the long-term result will not differ significantly from the ontable appearance.
Conclusion
The combination of titanium mesh cranioplasty and perforator based free tissue transfer has gained favor at our institution because of the ability to obtain a
reliable reconstruction in the setting of an attenuated soft tissue envelope.
169
Microsurgical Reconstruction Of Complex Scalp Defects: a Retrospective Follow-up Study
Institution where the work was prepared: Dep. plastic surgery, Erasmus MC, Rotterdam, Netherlands
Marc A.M. Mureau, MD, PhD1; Antoinette A. van Driel, MD1; Stefan O.P. Hofer, MD, PhD, FRCS(C)2; (1)Erasmus University Medical Center Rotterdam, (2)University
Health Network, University of Toronto
Purpose:
Reconstruction of complex scalp defects with exposed bone, sinuses, dura, or brain tissue usually requires a myocutaneous or fasciocutaneous free flap. Risk factors for
complications include chemotherapy, preoperative radiotherapy, cerebrospinal fluid leakage, and anterior defect location. There is a large variance in reported incidence
of postoperative complications. Aims of the current study were: to evaluate postoperative complication rates; to assess patient survival rates; and to compare our results
with previous series.
Matherials & Methods:
From January 2000 to February 2008, 28 consecutive patients were operated for a complex scalp defect using 30 free vascularized flaps. Patient characteristics, surgical data, complications, (neo)adjuvant chemo- or radiotherapy, and survival were scored retrospectively.
Results:
There were 16 males and 12 females with a mean age of 66.4 years (15-92 years). A total of 75% of the scalp defects resulted after wide excision of a (recurrent) basal or squamous cell carcinoma, 18% after resection of a brain tumor, and 7% were caused by other conditions. Mean defect size was 140 cm? (20-420 cm?). Nine patients (32%) had
exposed dura and 4 patients (14%) had exposed brain tissue. A total of 22 patients (79%) had one or more risk factors for impaired wound healing. Twenty patients (71%)
already had received a previous local reconstruction and 16 patients (57%) had received preoperative radiotherapy. A latissimus dorsi flap was used 14 times, an anterolateral thigh flap 12 times, a rectus abdominis muscle flap 3 times, and a radial forearm flap once. Mean follow-up was 39 months. Acceptor-site complications leading to re-operations were total flap necrosis (N=2; 7%), Skin graft failure (N=3; 11%), and hematoma (N=1; 4%). Both total flap losses were succesfully treated with a second latissimus dorsi
free flap. There were two donor-site skin graft wound infections (7%) requiring operative treatment. Seven patients (25%) underwent an additional operation for aesthetic reasons. Ten patients (64%) received postoperative radiotherapy. Six patients (21%) developed a local recurrence of the primary tumor of whom two patients eventually died. In total
11 patients died (39%) with a mean survival of 25 months (2 - 55 months). Mean survival of the patients alife was 49 months (3 – 75 months). Our data were comparable with
previous studies.
Conclusion:
Microsurgical reconstructions of complex scalp defects are technically feasible, even in older patients with multiple risk factors, after previous radiotherapy, and with a
shortened life expectancy. Complication type and incidence were in accordance with literature.
Definitive Treatment of Persistent Frontal Sinus Infections: Novel Reconstruction
and Complete Sino-Nasal Separation with Fibular Free Flaps
Institution where the work was prepared: R Adams Cowley Shock Trauma Center & Johns Hopkins University, Baltimore, MD, USA
Matthew G. Stanwix, MD1; Arthur J. Nam1; Helen Hui-Chou1; Hugo St. Hilaire1; Oliver P. Simmons1; Paul N. Manson, MD2; Eduardo D. Rodriguez1; (1)R Adams
Cowley Shock Trauma Center, University of Maryland School of Medicine, (2)Johns Hopkins School of Medicine
Background:
Frontal sinus injury involving nasofrontal outflow tract obstruction is routinely managed by obliteration or cranialization; however small percentages develop persistent
indolent infections despite routine measures. These patients suffer a prolonged symptomatic course with recurrent infectious bouts despite numerous conventional management attempts. Brain abscesses, subdural empyemas, and meningitis are rarely encountered, but prove the deleterious outcomes of improper partitioning of the upper
aerodigestive system from the anterior cranial base. We propose the fibular free flap as a single-staged novel treatment that definitively obliterates and separates the
nasofrontal outflow tract (NFOT) from the cranium in these patients.
Seven patients with persistent indolent infections associated with frontal sinus fractures were identified at R Adams Cowley Shock Trauma Center and Johns Hopkins
Hospital from 2005-2008.
Results:
There were three females and four males with an average age of 41 years. Injury resulted from motor vehicle collisions (n = 4), motor cycle collision (n = 1), fall (n = 1), and accidental (n=1). All patients were previously treated with conventional surgical techniques (average of 3.6 procedures and 11 years from initial injury) and prolonged antibiotic therapy without resolution of symptoms. Definitive treatment included radical debridement and obliteration with a free fibula flap in a single stage. Average bony defect after debridement was 11x7 cm. The fibula flap had an associated segment of flexor hallicus longus, average bony length of 8.5cm, and one osteotomy. All flaps were anastamosed to the
superficial temporal vessels. There was 100% survival, resulting in complete sino-nasal separation and eradication of infection. No donor site or frontal sinus complications were
encountered. Follow-up ranged from 5-27 months (average 15.3 months).
Conclusions:
Radical debridement, meticulous removal of the tenacious sinus mucosa and reconstruction with a free fibular flap in a single stage is a superb choice to eliminate persistent infectious complications associated with frontal sinus fractures in patients who failed conventional management. The fibular free flap achieves all goals of infectious frontal sinus reconstruction: provides a secure horizontal buttress, occludes the nasofrontal outflow tracts with vascularized muscle, and eliminates dead space.
Proper Management of Colo-esophageal Junction When Colon is Used for Reconstruction of Esophagus
Institution where the work was prepared: E-Da Hospital , Kaohsiung , Taiwan
Hung-Chi Chen, MD, FACS1; Samir Mardini, MD2; Salgado Salgado, MD2; Yueh-bih Tang, MD, PhD3; (1)E-da/I-I Shou University Hospital, (2)E-da Hospital,
(3)National Taiwan University
Background:
As a result of cancer ablation, the defect of pharyngo-esophagus can be reconstructed with a skin flap or an intestinal flap(either jejunal flap or colon, depending on the
size and level of pharyngeal defect). When a skin flap is used, a funnel-shaped skin tube can always be designed to meet the larger circumference of pharynx and the
smaller circumference of thoracic esophagus. However, when an ileocolon flap is used,with colon for reconstruction of esophagus (and ileal loop for voice tube), there is
a problem of size match between colon and thoracic esophagus.
Methods:
From 1996 to 2008, 74 cases of ileocolon flaps had been applied for reconstruction of esophagus and voice tube after total pharyngo-laryngectomy. In the first group
of the initial 18 cases the distal end of colon was partially closed and partially anastomosed to the thoracic esophagus. In the second group (after # 19) proper trimming
of distal colon segment on the antimesenteric side was performed to match the smaller caliber of the thoracic esophagus.
Results:
(1) The first group had two problems: (i) leakage in two patients (2/18). The leakage was treated with a secondary procedure for closure of wound. (ii) blockage of food
when the water of the food residue in the blind pouch had been absorbed. Six patients were treated with endoscope in the acute stage, followed by revision to remove
the redundant pouch. (2)In the second group neither leakage nor food stasis was found. The esophagogram showed smooth passage of the contrast medium. All the
patients in second group could eat semisolid or solid food at 2 months after surgery. Only two patients developed dysphagia following radiotherapy, and re-started regular oral intake at 5 months.
Conclusion:
Colon has mucosal folds which are different from the smooth surface of normal esophagus. It also has the capacity to absorb water. When colon is used for reconstruction of
pharyngo-esophagus proper trimming of the distal part of colon is a better choice to meet the size of thoracic esophagus, and the anastomotic site can be covered with fat
appendages. An excess pouch would cause dysphagia as a late complication.
170
Comparison of Radial Forearm Flaps and Medial Sural Artery Perforator Flaps
for Head and Neck Reconstruction
Institution where the work was prepared: Ching-Chun Lin, Taipei, Taiwan
Ching-Chun Lin, Resident, MD; Chang-Cheng Chang; Ming-Huei Cheng, MD; Fu-Chan Wei, professor; Huang-Kai Kao, MD; Chang-Gung Memorial Hospital
Introduction:
Defects in the head and neck after cancer ablation often led to disabling functional and cosmetic deformity. Selection of donor flaps is dependent upon the defect that is
to be reconstructed. For small to median size of defect in the head and neck region, the free radial forearm flap is commonly used. More recently, the free medial sural
artery perforator flap has been used for reconstructing defects of tongue, anterior mouth floor and shallow defect in the oral cavity. Thus, for supply of flaps for introral
defect, a comparison between radial forearm flap and medial sural artery perforator flap is provided in this study.
Between January of 2005 and April of 2008, 32 patients in whom 18 radial forearm flaps and 14 medial sural artery perforator flaps were used were evaluated.
Results:
The successful rate of the radial forearm and medial sural artery perforator flap was 100%. There was no significant difference in elevation time (57.5 min vs. 60 min)
or hospital stay (16.2 vs. 15.5 days). The overall complication rate for radial forearm flap was 10% and for medial sural artery perforator flap was 7%. However, the
radial forearm group had longer operation time because two-team working was not allowed. The disadvantages of the radial forearm flap include the conspicuous scar,
pain, numbness, tendon exposure and the sacrifice of a major artery. The medial sural artery perforator flap could achieve the same result without the associated donor
site morbidity if a six-cm-wide flap was elevated. There was no functional deficit in the medial sural artery perforator flap group. If the donor site could not be closed primarily, a skin graft is needed, which may be a problem for female patients. However, this is no concern for male patients.
Conclusion:
Our report highlights that radial forearm flaps and medial sural artery perforator flaps are very similar. However, medial sural artery perforator flaps appear superior in providing
larger skin territory, designing as the chimeric flap, allowing for two-team approach and less donor site morbidity.
Sub-Total Thigh Perforator Free Flap for Coverage of Large Soft-Tissue Defects
Neta Adler, MD1; Al B. Cohn, MD2; Mark Villa, MD3; Jayant P. Agarwal, MD4; Lawrence J. Gottlieb1; (1)University of Chicago, (2)Norwood Clinic, (3)MD Anderson
Cancer Center, (4)University of Utah
Introduction:
The closure or reconstruction of progressively more complicated and larger defects is a challenge for reconstructive microsurgeons. Although the anterolateral thigh (ALT)
flap and the anterior medial thigh (AMT) flap have gained great popularity, their maximal dimensions may be insufficient for the reconstruction of very large or complex
wounds. We present our experience with reconstruction of massive soft tissue using sub-total thigh perforator free flaps incorporating skin territories supplied by both the
lateral and medial vascular systems of the thigh. Utilized in continuity, these skin territories can provide nearly circumferential thigh flaps. With skin paddles and muscles
isolated on individual perforators, these free style flaps may be designed as chimeras and can provide an almost limitless three dimensional variability for the reconstruction of complex defects.
Methods and Materials:
Between April 2005 and February 2008, six patients with large or complex defects from ablative oncologic surgery for upper extremity, scalp and oropharyngeal tumors
were reconstructed using free-style sub-total thigh perforator free flaps incorporating both lateral and medial perforators by the senior author. The size of flaps ranged
from 500 cm2 to >1200 cm2 . One was used for shoulder coverage, two for anterior neck, upper chest and pharyngo-esophageal reconstruction and three were used
for large scalp defects. All donor sites were closed with split thickness skin grafts.
Results:
All defects were reconstructed in a single step with a single flap. All flaps were based on the lateral and medial (innominate) descending branch of the lateral femoral circumflex. In 3 of the cases the vessels coalesced into one artery and one vein and in 3 of the cases the lateral and medial systems did not merge into one pedicle and additional anastomoses were required. All flaps survived. One patient had a minor wound breakdown. One patient died from a tracheo-innominate fistula two months postoperatively. All donor sites healed and all patients successfully ambulated during their first post-operative week with a knee immobilizer.
Conclusion:
The free style sub-total thigh free flap enables reconstruction of massive defects based on the lateral and medial perforators from the lateral femoral circumflex system.
They allow for flaps with a wide variety of shapes and potential skin paddles and can provide both the large surface area and substantial three-dimensional variability
frequently required for complex reconstructions. When the medial system does not come off the same main pedicle due to anatomic variations, additional anastomoses
is needed.
Outcome Comparisons between Soft-tissue Flaps and Bone-carrying Flaps for Reconstruction
of Cordeiro Type II and IIIa Maxillectomy Defects Following Oncological Resection
Chih-Wei Wu, MD; Jung-Ju Huang; Huang-Kai Kao; Chung-Kan Tsao; Ming-Huei Cheng; Chang Gung Memorial Hospital, Chang Gung University and Medical College
Purpose:
Management of the Cordeiro type II or III maxillectomy defects remains a challenge to reconstructive surgeons. Controversy regarding soft-tissue versus bone flaps in terms
of adequacy of volume and benefit of bony reconstruction remains unresolved. To overcome the inadequate volume of bone-carrying flaps, a portion of soleus was included in the fibular osteoseptocutaneous flap based on the peroneal vessels as an osteomyocutaneous peroneal artery-based combined (OPAC) flap. The purpose of this
study was to compare soft-tissue flaps (anterolateral thigh myocutaneous flaps) with bone flaps (OPAC flaps) for reconstruction of Cordeiro type II or III maxillectomy defects.
Between 2001 and 2007, 15 patients underwent free flap transfers for type II and IIIa maxillectomy defects. Fourteen patients were available for long-term evaluations
(median follow-up, 26 months). Nine patients underwent OPAC flap transfers for type II defects in 6 cases and type IIIa defects in 3 cases (bone group). Five patients
underwent anterolateral thigh myocutaneous flap transfers for type II defects in 3 cases and type IIIa defects in 2 cases (soft-tissue group). For type IIIa defects, orbital floor
reconstructions were accomplished by osteotomized fibula when OPAC flaps were used or rib graft with/without titanium mesh when anterolateral thigh flaps were used.
Outcomes were assessed according to speech, diet, and cosmesis evaluations using 4-point scoring systems. Statistic analysis (unpaired t-test) was used to determine the
differences in scores between two groups.
Results:
Total flap loss occurred in one anterolateral thigh flap but none of the OPAC flaps, giving a success rate of 92.8%. Sunken cheek occurred in 80% (4/5) of soft-tissue
group patients and 33% (3/9) of bone group patients. Sixty percent (3/5) of the soft-tissue group patients experienced cheek sagging but none of the bone group patients
did. Cheek cosmesis scores were significantly higher in the bone group than the soft-tissue group (3.2 versus 2.2; p < 0.05). There was no statistical difference in scores
of speech intelligibility, diet and lower eyelid cosmesis between two groups, but the severity of lower eyelid retraction was significantly higher in the soft-tissue group.
Conclusion:
Our results showed that bone-carrying flaps are superior to soft-tissue flaps in reconstruction of Cordeiro type II and IIIa maxillectomy defects in terms of functional and
cosmetic outcomes; bone-carrying flaps (OPAC flaps in this study) reconstitute bony projection, prevent cheek sagging and depression, reduce lower eyelid retraction and
produce long-lasting aesthetic results.
171
Perforator Topography of the Medial Sural Perforator Flap and Clinical Application in Head and Neck Reconstruction
Ying-An Chen, MD; Huang-Kai Kao, MD; Ming-Huei Cheng, MD; Fu Chan Wei, MD, FACS; Chang Gung Memorial Hospital
The medial sural perforator flap is a thin and pliable flap that can serve as an alternative to the radial forearm flap.Although the anatomic study has been investigated in cadavers of several series,there are few clinical reports of topographic data.Furthermore,the experience with the use of this flap was mostly in extremity reconstruction.This study investigates the perforator topography of the medial sural perforator flap and its clinical application in head and neck reconstruction. Materials and Methods: From 2005 to 2007,fourteen patients underwent medial sural perforator flap transfers for head and neck reconstruction following oncological resection.Among them,13 patients had intraoral defects and
the other one had a scalp defect.Flap harvest was performed in a supine position with hip abducted and knee flexed.Three lines were marked:(1)popliteal crease(2)midpoint of
popliteal crease to Acchilles tendon(posterior calf midline)(3)distal border of medial gastrocnemius muscle.Hand-held Doppler was used for preoperative mapping of
perforators.The distance from the perforator perpendicular to popliteal crease was defined as X and to posterior calf midline was defined as Y.The flap was raised from medial
margin without tourniquet to identify all musculocutaneous perforators.The sizable(>0.5mm)perforators were dissected to the main trunk,the medial sural vessels,with preservation of sural nerve and lesser saphenous vein. Results: All flaps had an average of 2.7 perforators and all of them had at least one sizable perforator with an average of 1.5(range
1-3)in a region between 6cm and 18cm from popliteal crease and between 1.5cm and 6cm medial to posterior calf midline.The distribution of perforators was plotted to the
coordinate system using two axes:X/Y and most of them centralized at X/Y:8-12/2-4.The average pedicle length was 11.9cm and the mean flap thickness was 4.7mm.Flap size
ranged from 4x8cm2 to 12x14cm2.The donor site was closed directly in 8 patients and skin grafted in the others.All flaps survived without vascular insufficiency or partial loss.All
patients achieved good functional and aesthetic outcomes without any revision procedure. Conclusion: Our study showed that the medial sural perforator flap is suitable for head
and neck defects particularly for whom the source of thin cutaneous flaps is limited.Its perforators are reliable and could be precisely localized by Doppler in the region we
described.The pedicle dissection is relative easy due to straight intramuscular course and consistent anatomy.Compare to the forearm flap,this flap provides similar characteristics but preserves major vessels at donor site.In selected head and neck defects,the medial sural perforator flap is ideal and reliable to be used for reconstruction.
Osseointegrated Dental Implants in Patients with Head and Neck Cancer
Matthew M. Hanasono, MD; Roman J. Skoracki, MD; Martina Ayad, BS; Neha Goel, BS; Rhonda Jacob, DDS; Suyu Liu, MS; Peirong Yu, MD; The University of Texas
M. D. Anderson Cancer Center
Background:
Functional prosthetic oral rehabilitation following tumor resection and/or radiotherapy is often unsuccessful due to altered tissue contours and xerostomia. We sought to
evaluate outcomes with osseointegrated implant-based dental rehabilitation in head and neck cancer patients without reconstructive flaps, with soft tissue free flaps, and
with osteocutaneous free flaps
Methods:
From 2003 to 2007, 431 osseointegrated dental implants were placed in 98 patients with head and neck cancer. Forty-eight percent of patients were smokers. Thirteen percent of
patients received radiation prior to implantation and 51% received radiation after. Osseointegrated implants were placed at the time of oncologic therapy in 66% and delayed in
34%. Sixteen percent of patients underwent reconstruction with an osteocutaneous free flap and 29% with a soft tissue free flap while 55% did not require a flap due to limited or
no oral resection.
Results:
The average length of follow-up was 20 months. At the time of last follow-up, 68% of patients had received a dental prosthesis. Of patients who underwent osteocutaneous free
flap reconstruction, 31% required hardware removal to accommodate implants. Seventy-two percent of patients who underwent free flap reconstruction required flap thinning to
accommodate a prosthesis. Preoperatively, 86% of patients consumed a regular diet, 11% a soft diet, and 1% a pureed diet. Postoperatively, 47% of patients consumed a regular diet, 39% a soft diet, 7% a puree diet, and 8% were tube feed-dependent. At the time of last follow-up, 88% of patients were alive and 21% of patients had recurrent cancer.
Implant-associated complications occurred in 12% of patients, including 6 patients with loss of one or more implants due to failure of the implant to integrate, 4 patients who
developed osteoradionecrosis limited to the in the implant region, and 1 patient who had a fibular free flap fracture. The implant survival rate was 97.7%. Tobacco use, radiotherapy, chemotherapy, and the timing of implant placement were not significantly related to the occurrence of complications. Implant-associated complications were highest in
patients who did not have free flap reconstruction (p<0.05).
Conclusions:
Osseointegrated dental implants have a high success rate in head and neck cancer patients even with significant risk factors for poor wound healing. Alveolar coverage
with well-vascularized free flap tissues appears to be related to higher success rates. Careful selection of patients most likely to benefit from implants and at low risk for
complications is critical in the head and neck cancer population.
Microvascular Reconstruction of Mandible Defects Due to Gunshot Injuries
Selçuk Isik; Ismail Sahin; Mustafa Nisanci; Serdar Ozturk; Mustafa Deveci; Cengiz Acikel; Gülhane Military Medical Academy
Introduction:
Mandibular reconstruction has been presenting a significant challenge for reconstructive surgeons. However, the advance of microvascular and maxillofacial surgical principles has brought a new dimension to overcome the difficulties in this era.
Between 1992-2008, 114 patients with mandibular gunshot injuries were treated in the Department of Plastic and Reconstructive Surgery at Gülhane Military Medical
Academy. In 34 cases, the bony defects were treated with free flap transfers, which 21 were osseous and the remaining flaps were in osteocutaneous fashion. Of these
34 patients, 13 were treated with a free fibula flap transfer in the early period. Vascularized fibula flap (in 19 patients) and DCIA flap (in 2 cases) were used for definitive treatment of bone defects. Bone grafts were used if the mandibular defect was less than 4 cm. Other cases were treated either by bone graft or distraction osteogenesis. In three patients, vertical distraction osteogenesis of the osteocutaneous fibula flap was performed for implant placement. Dental prosthetics were routinely employed.
Results:
The average bony defect was 6.7 cm (range, 4-9 cm). The definitive treatment was preferred to be performed in the early period but it was possible only in 13 cases. In
19 cases, late reconstructions were performed. A near-normal occlusion was obtained in all cases. Postoperative complications included loss of free fibula flap (4 cases),
loosening of plate (9 cases), nonunion (2 case) and plate fracture (1 case). A second free fibular flap was performed to those with free flap loss.
Conclusion:
We recommend reconstructing large bone defects by vascularized bone flaps in the early periods. Early reconstruction of the mandibular gunshot injuries has several advantages such
as better functional and cosmetic outcome, decreased hospitalization and cost. Defect should be bridged by use of a reconstruction plate if early definitive treatment is not possible.
172
Tongue Reconstruction with free tissue transfer: An experience with 110 cases
Holger Engel, MD1; Emre Gazyakan, MD, ;, MSc2; Jung-Ju Huang, MD1; Shu-Ying Chang, MD1; Ming-Huei Cheng, MD, MHA1; (1)Chang Gung
Memorial Hospital, (2)Chang Gung Memorial Hospital
Introduction:
Reconstruction following resection of malignant tongue tumors remains one of the most difficult problems in head and neck surgery. The tongue plays a critically important role in speech and swallowing function. Successful functional rehabilitation after major tongue resection should be the goal of reconstructive surgery. We present our experience in 110 cases of tongue reconstruction with free tissue transfer.
Methods and Patients:
From February of 2000 through April of 2006, 110 tongue reconstructions with free tissue transfer were performed. Among those there were 69 (63%) free
ALT flaps, 29 (26%) radial forearm flaps, 8 (7%) free fibula flaps, 1 (1%)free soleus peroneal artery perforator flap, 1 (1%) first metatarsal bone composite tissue transfer, 1 (1%) thoracodorsal artery perforator flap and 1 (1%) DIEP flap. Eight (7%) female patient and 102 (93%) male patients with an average age
of 49 years (range from 30 to 82) were admitted with left (41), right (32) and bilateral (37) tongue cancer. Among those there were 23 patients with extended involvement of mouth floor, gingiva, external cheek, soft palate, retromolar trigone area and lower lip. TNM data could be evaluated from 75 (68%) patients.
There were 34 (45%) patients with a T2, 19 (25%) patients with a T3 and 22 (30%) patients with a T4 tumor. Six patients received radiotherapy, 4 patients
chemotherapy and 10 patients presented with a recurrent tumor. Only 11 (10%) patients were lost to follow up. (range from 1 to 70 months, average 30
months).
Results:
Functional results were evaluated in 35 (32%) patients for speech and diet. 13 patients (37%) had a normal speech postoperatively, 12 (34%) with slurred
speech and 10 patients (29%) were intelligible. 16 patients (46%) could eat normally, 9 patients (26%) required soft diet, 8 (23%) liquid diet, 2 (5%) nasogastral feeding. Overall success rate was 97% with a total flap loss in 3 patients due to thrombosis (2 patients) and hematoma/antikoagulation disorder (1 patient).
Partial flap loss occured in two patients which could be skin grafted.
Conclusion:
Tongue cancer resection and subsequent reconstruction is challenging to the surgeon with regard to a good postoperative functional result. In this series with could
demonstrate an excellent overall flap survival rate and good functional results despite extensive tumor infiltration and complex defects after tumor resection.
173
ASRM Poster Presentations
Peripheral Nerve Tumors in Children: An Update on Nomenclature and Case Report
Institution where the work was prepared: The Hospital for Sick Children , Toronto, ON, Canada
Vanessa Hew-Ling Wong, MD1; T.K.S. Cypel, MD1; Bo Ngan, MD2; William Halliday, MD3; R.M. Zuker1; (1)University of Toronto/ The Hospital for Sick
Children, (2)The Hospital for Sick Children, (3)University of Toronto
Background:
Peripheral nerve tumors comprise less than five percent of all tumors of the hand in the pediatric population. The most common solitary tumor of peripheral
nerves is the schwannoma. This benign tumor is more common in adults between 20 and 50 years old and and uncommon in pediatric population. In children, these tumors mainly involve the head, neck and upper extremity but rarely affect the digits. Due to the paucity of reported cases, the diagnosis and nomenclature of these tumors is confusing.
Based on a case report we discuss the current nomenclature, pathological features, epidemiological characteristics, presentation, differential diagnosis, and
management. A clinical case of a locally aggressive and recurrent plexiform schwannoma involving left index finger of sixteen-month old girl is also presented. The diagnosis of plexiform schwannoma was confirmed by features of histological analysis. After a primary total resection, a local recurrence appeared
within five months. She is otherwise healthy and is asymptomatic. The schwannoma involved the radial digital nerve and dorsal digital nerve at the time of primary and secondary resection, respectively.
Discussion and Conclusion:
Excluding cutaneous malignancy, 95% of tumors of the hand are benign. Schwannomas manifest as asymptomatic swellings along the course of a peripheral
nerve and are uncommon in children. A precise diagnosis and treatment are crucial to determine the prognosis and quality of life in the pediatric population.
The Use of Supermicrosurgery in Lower Extremity Reconstruction
Institution where the work was prepared: Asan Medical Center, University of Ulsan, Seoul, South Korea
Joon Pio Hong, MD, PhD, MMM; Asan Medical Center, Univeristy of Ulsan
Introduction:
The purpose of this study is to evaluate the feasibility of supermicrosurgery (perforator to perforator anastomosis) in lower extremity reconstruction.
Method and Material:
From January of 2007 to February of 2008, total of 42 patients have been treated for soft tissue defect of the lower extremity due to various etiology. They
were reconstructed with either anterolateral thigh perforator flap (38 flaps) or upper medial thigh perforator flap (4 flaps) using supermicrosurgery technique.
The region of defect was located on the knee including the upper 1/3 of the leg in 17 patients and mid 1/3 of the leg in 25 patients. All the flaps were anastomosed between the perforators in end to end fashion.
Result:
With the exception of 1 flap, all flaps survived without any complication. One flap was observed to have no flow after 24 hours and was deemed unsalvageable. The average time of operation was 3 hours and 20 minutes. Ambulation was allowed within 7 days after surgery if bone status was feasible.
Conclusion:
The use of supermicrosugery in lower extremity reconstruction allows an increase in selection of recipient pedicles. By using a perforator to perforator anastomosis approach, less time is consumed to secure the recipient vessel, to elevate the flap and minimizes any risk for major vessel injury while having acceptable
flap survival. However, it requires a learning curve before the technique can be comfortably used. The supermicrosurgery technique is feasible and may be
efficient in the hands of a skilled surgeon.
174
Donor Site Morbidity after Free Ileocolon Flap Transfer
Hung-Chi Chen, MD, FACS1; Bahar Bassiri Gharb1; Antonio Rampazzo1; Christopher J. Salgado, MD2; Samir Mardini, MD3; Stefano Spanio di
Spilimbergo1; (1)E-da/I-I Shou University Hospital, (2)University Hospitals Cleveland / Case Western Reserve University, (3)Mayo clinic Rochester
Background:
Radical excision of advanced hypopharyngeal and laryngeal tumours usually compromises both swallowing and speech. Among the available reconstruction
methods, the free ileocolon flap allows rehabilitation of both functions in one stage. The donor site morbidity of this flap has not been addressed in head and
neck cancer patients.
Methods:
A retrospective study was conducted between July 2004 and December 2007 to investigate donor site morbidity in patients undergoing reconstruction with
free ileocolon flaps. Complications such as diarrhea, upper gastrointestinal distress, bowel leak, abscess, or hernia formation were evaluated. Significant correlations with associated complications were identified. Subsequent complications were evaluated such as diarrhea, upper gastrointestinal distress, age? 55
years, previous abdominal operations, systemic diseases, primary versus secondary reconstruction, flap length (ileocolon or ileocecal patch) and postoperative
chemotherapy were subsequently evaluated. Differences were considered significant if p ≤ 0.05.
Results:
There were no perioperative or postoperative deaths. Nineteen patients (56%) experienced diarrhea. In all patients, except 2, diarrhea expired by 4 months.
Chemotherapy was significantly associated with diarrhea (p<0.01). Colchicine, Terbinafine and heroin withdrawal episodically caused diarrhea but statistical
conclusions could not be drawn. Six patients (25%) suffered from upper gastrointestinal problems (gastroduodenal ulcer, erosive gastritis and minor bleeding)
probably due to insufficient gastric protection.
Conclusions:
Free ileocolon flaps proved to be a safe method for restoration of swallowing and speech in this high risk group of patients with a donor site morbidity comparable to the other intestinal flaps.
Unilateral Flap Failure in Bilateral Microvascular Breast Reconstruction:
Outcomes in 342 Flaps and Strategies for Management
Pranay M. Parikh, MD; Mark W. Clemens; Maurice R. Nahabedian; Georgetown University
Background:
As rates of bilateral prophylactic mastectomy and contralateral prophylactic mastectomy have increased over the past decade, techniques of bilateral microvascular breast reconstruction have played an increasing role in breast cancer care. Data on unilateral flap failure in the setting of bilateral microvascular breast
reconstruction has been lacking, and strategies to address the challenges encountered in this situation are needed.
Methods:
A retrospective review of all simultaneous bilateral microvascular breast reconstructions performed by the senior author was performed. Flap failures were identified and reviewed for operative parameters, causes of flap loss, and techniques used for secondary reconstruction.
Results:
We identified 171 consecutive patients who underwent bilateral microvascular breast reconstruction between 1999 and 2008. 342 flaps were attempted including 108 free TRAM flaps, 228 DIEP flaps, and 6 SGAP flaps. 12 flaps failed or were aborted intraoperatively, yielding an overall failure rate of 3.5%. No
cases of bilateral failure were observed. 8 failures occurred in immediate reconstructions and 4 failures occurred in delayed reconstructions. Causes of flap failure included venous insufficiency (6/12), lack of adequate perforator anatomy (3/12) and perforator injury during dissection (2/12). Secondary reconstruction with tissue expanders and implants was successful in 12/12 patients who underwent an average of 2.25 additional procedures to complete reconstruction.
Conclusions:
Bilateral microvascular breast reconstruction can be performed with an acceptably low failure rate in both immediate and delayed settings. However, flap failure is more common in bilateral reconstructions than in unilateral reconstructions. During bilateral abdominal flap reconstruction, the greater concern for donor
site muscle preservation, and lack of a “lifeboat” flap increase the technical demands of the operation. To maximize flap success, minimize morbidity, and optimize aesthetic outcomes we recommend:
• Critical assessment of both hemi-abdominal flaps in-situ for perforator anatomy and quality.
• Preferential preservation of innervated muscle on the side with more favorable perforator anatomy to preserve dynamic abdominal wall function.
• A low threshold to use MS-TRAM techniques on the side with less favorable perforator anatomy to optimize flap success
• Preferential use of the more robust hemi-abdominal flap for reconstruction of the side most likely to receive adjuvant radiation.
• Completion of secondary prosthetic reconstruction to replace the failed flap, prior to any revision of the successful flap.
• Tailoring of the successful flap to match the prosthetic reconstruction to optimize post-operative symmetry and aesthetics.
175
Preoperative Perforator Imaging in Reconstructive Microsurgery – Current Practice in Germany
Institution where the work was prepared: Plastic, Hand and Reconstructive Surgery, Medical School, Hannover, Germany
Karsten Knobloch, MD, PhD; Andreas Gohritz; Ebischa Reuss; Peter M. Vogt; Hannover Medical School
With the advent of perforator-based flap designs in reconstructive plastic surgery preoperative assessment of perforator flaps has obtained significant attention during the last
decade. Starting in 1994 color duplex sonography has been proposed for preoperative identification and calibration of relevant perforators, followed by MRI and recently threeand even four-dimensional computer tomography and MRI for preoperative perforator mapping. Despite the preoperative visualization of perforators with recent advances in
imaging technology, the current clinical practice of preoperative perforator monitoring is still disputed. We questioned a total number of 121 German plastic reconstructive surgeons regarding their current practice in perforator-based reconstructive microsurgery. 45% performed perforator-based flaps on a routine basis. Pre-operative perforator imaging was performed in 90.4% among German plastic surgeons. The majority performed Duplex sonography (72%) followed by color Doppler sonography (48%). Only 4% of all
plastic surgeons performed a preoperative angio-CT and 4% performed angio-MRI (table 1). Depending on the number of perforator flaps performed per year, the preoperative perforator diagnostic was determined. Those surgeons, who performed performing more than 30 perforator flaps per year, used either Duplex or color Doppler sonography, but did not use angio-CT or angio-MRI for preoperative perforator imaging. About one-third of all plastic surgeons used a combination of these diagnostic techniques. The
majority combined Duplex- and color Doppler sonography (28%), while only 2% combined Duplex sonography with angio-CT and 2% color Doppler with angio-MRI (table 2).
From this data we conclude that albeit the proven efficacy and reliability of angio-CT or angio-MRI for perforator imaging, duplex and color Doppler sonography remain the
preferred tools for preoperative perforator diagnostic in Germany. Furthermore, clinical trials are pending to demonstrate that the preoperative perforator imaging shows beneficial effects in improving clinical outcome or the ease of flap dissection and in reducing theatre time with lower financial case costs. Thus lower financial case costs and lower
postoperative complications based on a thorough preoperative planning of perforator flaps may be the result of the current advances in imaging technology.
Anterolateral Thigh Flaps in Children: Clinical Observation of Perforator Development
Christopher J. Salgado, MD1; Samir Mardini, MD2; Hung-Chi Chen, MD, FACS3; Bahar Bassiri Gharb3; Stefano Spanio di Spilimbergo3; Antonio Rampazzo3;
(1)University Hospitals Cleveland / Case Western Reserve University, (2)Mayo clinic Rochester, (3)E-da/I-I Shou University Hospital
Background:
Many structures in children, particularly perforators, have not completed their development. The anterolateral thigh (ALT) flap is considered a workhorse flap in reconstructive surgery, particularly for large defects or those involving multiple tissue components (tendon or muscle). Flap reliability in children is of paramount importance. We
describe our clinical experience with this flap in the pediatric population.
A retrospective review was performed on all pediatric patients (<16 years of age) who underwent a free ALT flap reconstruction. Seventeen patients from '96 to '08 were reviewed.
There were 9 males and 8 females with an average age of 9.6 years (youngest 2 years). Defects were following trauma, release of severe contractures, and exposed hardware.
Particular attention was paid to the number and diameter of perforating vessels to the skin paddle. Flap survival, donor site morbidity, and final outcome was assessed.
Results:
There were no flap losses and no significant donor morbidity (seroma, hematoma, difficulty ambulating) recorded. Flap dissection was not noted to be particularly more
difficult than in adults. All children had well-developed perforators (average 2-3 per skin paddle) with average arterial and venous diameters of 1 mm and 1.4 mm respectively. The operating microscope was used for anastomosis of vessels in all cases and for dissection of the perforator vessels during the harvest in 14 cases.. The perforator vessels were smaller than in the adults and there was a shorter intramuscular or septal course of dissection.
Conclusion:
Our series demonstrates that children have well-developed perforator vessels supplying the anterolateral thigh flap. Therefore, with proper technique and liberal use of the
microscope, this flap can be harvested and used safely and reliably for reconstruction of varied defects in children.
176
Latissimus Dorsi Chimeric Free Flap Reconstruction in Complicated Scalp and Calvarial Defects
Institution where the work was prepared: University of Chicago Hospitals, Chicago, IL, USA
Iris A. Seitz, MD, PhD; Neta Adler, MD; Eric Odessey, MD; Russel Reid, MD, PhD; Lawrence J. Gottlieb, MD; University of Chicago
Background:
Adequate coverage of complex, composite scalp and cranial defects in previously radiated, infected or otherwise compromised tissue represents a challenge in reconstructive surgery. In order
to provide wound closure with bony protection to the brain, improved cranial contour, and prevention or sealing of cerebrospinal fluid leaks, composite free tissue transfer is a reliable and safe
option. We report our experience with five latissimus dorsi/rib intercostal perforator myo-osseo-cutaneous free flaps to reconstruct bony and soft tissue defects of the cranium and overlying scalp.
Methods:
The surgical technique, design and outcome of the latissimus dorsi/rib intercostal perforator myo-osseo-cutaneous free flap reconstruction in five patients with cranial defects between 2003
and 2007 were retrospectively evaluated. Patient characteristics, defect size and underlying cause, reconstructive details and complications were analyzed.
Results:
All patients (age 43 to 81) had complex cranial defects, mean size being 230cm2 (36-750cm2), two with cerebral spinal fluid (CSF) leak. Two patients had cranial defects due to
malignancy (squamous cell carcinoma of the scalp, brain tumor with CSF leak), one patient had infiltrative cutaneous mucormycosis with osteomyelitis, one patient had infection of a
failed cranioplasty after craniectomy for hemorrhagic stroke and one had continuous CSF leak after craniectomy for hemorrhagic stroke. Follow up ranges from 7-26 months.
Complications included vascular compromise of one flap salvaged by vein graft, limited distal flap necrosis in three patients that was treated with local debridement and topical antimicrobial agents. No flap losses and no donor site complications were noted.
Conclusion:
The latissimus dorsi chimeric free flap consisting of skin, muscle and vascularized rib based of the thoracodorsal artery can successfully cover large complex cranial defects, provide skeletal support, restore contour and significantly improve functional outcome with limited donor site morbidity.
Use of the Posterior Tibial Perforator Free Flap for Soft Tissue Reconstruction of Extremities
Institution where the work was prepared: Sungmin General Hospital, Incheon, South Korea
Gi-Doo Kwon, MD; Byung-Moon Ahn, MD; Sungmin General Hospital
Purpose:
Though there have been many anatomic studies about posterior tibial perforator flap so far, clinical applications have not been used popularly. Based on various literatures, the authors of this
study reconstructed the soft tissue defects of the hand and foot using the posterior tibial perforator free flap and present the report of the results.
Between November of 2006 and November of 2007, we used posterior tibial perforator free flaps in 10 patients. All the patients were male, with average age of 37.6 years (range 23-47 years).
The mean follow-up periods were 14 months. Various sizes of flaps were used from 3?4 cm to 14?8 cm, averaging 46 cm2. The causes of injuries included press by industrial machinery during work
(7 cases), motor vehicle accident (2 cases) and by rope (1 case). The recipient sites were 7 cases of the hands and wrists, 3 cases of the toes and feet.
Results:
The diameter of the posterior tibial perforator was 0.75 mm (s.d. 0.19 mm, range 0.5-1.0 mm), and the length from the posterior tibial artery to the flap was an average of 4.5 cm (s.d.
0.77 cm, range 3-5.5 cm). The location of perforators was an average of 15.4 cm (s.d. 2.4 cm, range 14-22 cm) from the medial malleolus, and the site was around 51 % of the length of
the lower leg. The transferred flaps completely survived in 8 cases and there were 2 cases of partial necrosis. One case of 20 % necrosis was treated with debridement and suture and the
other case of 40% necrosis was treated with abdominal flap at another hospital. In 3 cases, defatting was performed due to bulky flap.
Conclusion:
We successfully reconstructed 10 cases of traumatic soft tissue defects of extremities using posterior tibial perforator flaps. The posterior tibial perforator free flap is thin and may be
used as a composite flap because it can include nerve, muscle, and bone. However, prominent postoperative donor site scar and the pedicle has a small diameter, short length, and
uncertainty of location. Thus, it may be used with limited indication, and it needs sufficient preoperative evaluation and expert techniques.
A Novel Flap for Face and Scalp Allotransplantation
Institution where the work was prepared: Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
Jesse A. Taylor, MD; Rian A. Maercks, MD; Chris Runyan, PhD; Donna C. Jones, PhD; Christopher B. Gordon, MD; Cincinnati Children's Hospital Medical Center
Introduction:
Conventional reconstructive procedures for face and scalp reconstruction fall short of aesthetic and functional goals because of the unique quality and character of face and scalp soft tissue.
Additionally, the surface area requirements for resurfacing the full face and scalp exceed the limits of many modalities. This study in cadavers demonstrates the feasibility of a novel flap design
for full face and scalp composite tissue allotransplantation.
Methods:
Three fresh human cadavers were dissected. Novel incisions provided for full face and scalp harvest without incisions on facial skin. Dissection in the submuscular plane allowed for
inclusion of the carotid and jugular systems. Time of facial-scalp flap harvesting, length of the arterial and venous pedicles, length of sensory nerves that were included in the facial flaps,
and approximate surface area of the flaps were measured.
Results:
In the donor cadaver, the mean harvesting time of the total facial-scalp flap was 109 ± 35 minutes. The mean length of the supraorbital, infraorbital, mental, and great auricular
nerves were 1.3 ± 0.5, 1.3 ± 0.2, 1.3 ± 0.2, and 5.3 ± 1.7 cm, respectively. The mean length of the external carotid artery and external jugular vein were 8.2 ± 0.4 and 8.7 ± 1.2
cm, respectively. The approximate area of the harvested flap was 1040 ± 47 cm2.
Discussion:
In preparation for full face and scalp allotransplantation in humans, we have demonstrated the feasibility of a novel full face and scalp flap without facial incisions.
Pedicled Thoracodorsal Artery Perforator Flap in Breast Reconstruction:Clinical Experience
Neta Adler, MD; Iris Seitz; David Song; University of Chicago
Background:
The thoracodorsal artery perforator (TAP) flap has been described for reconstruction of the head and neck, trunk and extremities. Yet, its use as a pedicled flap in breast reconstruction has not gained wide popularity and has not been widely documented, especially not for complete breast reconstruction or in combination with expanders or permanent implants.
The authors present their clinical experience with the thoracodorsal artery perforator flap in breast reconstruction.
Methods:
From February 2007 to May 2008, eleven patients had breast reconstruction utilizing a TAP flap – eight cases of complete reconstruction and three cases of partial reconstruction.
Retrospective analyzes of patient characteristics, breast history, clinical indications, complications and outcomes were performed. The follow-up period ranged from 1 to 9 months.
Results:
Eight patients had complete breast reconstruction using a TAP flap with simultaneous insertion of an expander or implant. The three other cases were partial reconstructions to gain
additional volume after previous breast reconstruction. All flaps healed well. One case required evacuation of hematoma in the operating room two days after reconstruction and had
a small skin breakdown which healed secondarily. In another case there was late extrusion of the expander after expansion in the previously irradiated tissue, requiring expander
removal. There were no donor site complications.
Conclusions:
The TAP flap has proven to be a reliable flap with minimal donor site morbidity. It has replaced the Latissimus dorsi flap in our practice for autologus partial breast reconstruction or
for complete breast reconstruction in women with contraindication or who are unwilling to have breast reconstruction from abdominal tissue.
177
Reconstruction of Soft Tissue Defect of Lower Extremity with Free SCIA/SIEA Flap
Institution where the work was prepared: Serdar Nasir, Ankara, Turkey
Serdar Nasir1; Mustafa Asim Aydin, MD2; Safak Tunc1; Abdullah Kecik, MD1; (1)Hacettepe University, (2)Suleyman Demirel University
Introduction:
Free tissue transfer is the most important means of soft tissue reconstruction for the lower extremity. However, cosmetic results and donor site morbidity are only of secondary concern of lower extremity reconstruction. Our efforts to obtain the best possible outcome for patients, as our first priority we chose free superficial circumflex inferior
artery (SCIA) / superficial inferior epigastric artery (SIEA) flap over other free flaps options in the soft tissue reconstruction of lower extremity due to some advantages.
From 2003 to 2006 25 patients with extensive tissue loss in lower extremity were treated with 27 free SCIA/SIEA flaps. Two flaps were performed at same
time in two cases. Nine patients were female and 16 were male. Patient's ages ranged from 21 to 81 with a mean age of 36 year. . The indications for reconstruction included high energy injured trauma in 16 cases; burn contracture release in 6 cases, tumor resection in 2 cases, and high voltage burn injury in one.
The soft tissue defects were described as follows: knee in 4 cases, proximal and middle part of the leg in 10 cases, distal part of the leg in 7 cases, foot in 3
cases, heel in 3 cases. The size of the soft tissue defects ranged between 45 cm2 and 600 cm2 (mean, 150 cm2 It was selected SIEA which was preferred to
intend thick flap while SCIA was used for reconstruction with thin flap. The selected arterial pedicle was SCIA (n=9), SIEA (n=15), or their common trunk (n=3).
The pedicle artery of the flaps were anastomosed with posterior tibial artery (n=15), anterior tibial artery (n=7), dorsalis pedis artery (n=4), and lateral genicular artery (n=1). The success rate of our flaps series was 96% (26/27). Secondary debulking under local anesthesia was performed with suction lipectomy in
3 patients between 1 and 3 months at postoperative period. The functional and aesthetic results were evaluated as acceptable in all patients
Conclusion:
Free SCIA/SIEA flap has the following advantages in soft tissue reconstruction of lower extremity: (1) Large flaps may be harvested for extensive defect and/or
to reach recipient artery for passing zone of injury; (2) if necessary, final flap debulking may be performed by surgical procedure using local anesthesia; (3)
The donor site is closed in a similar manner to abdominoplasty incision so that excellent cosmetic result may be achieved.
Long Term Survival of Penile Allograft Transplant in Rat Model under Cyclosporin-A Monotherapy
Erhan Sonmez, MD; Serdar Nasir; Maria Siemionow; Cleveland Clinic
Introduction:
The treatment options for penile defects include: penile replantation, reconstruction and transplantation. In this study we introduce an experimental model of
penile allogenic transplantation based on neurovascular pedicle.
Methods:
42 adult male LEW(RT1l) and 6 adult male LBN(RT1l+n) rats were used in three experimental groups: Anatomic study (n=6), isotransplantation (n=24) and
allotransplantation groups (n=12). In 6 LEW rats, the vascular anatomy of male rat perineal region was determined by anatomic dissections. The penile composite flap was created based on the corpus spongiosum, dorsal penile vein and dorsal penile nerves. In 12 LEW rats, penile composite graft was transplanted as an isotransplant by microvascular anastomosis of the pedicle of the penis of the donor with the saphenous vessels of the recipient. In another 12 LEW
rats, penis was transferred as a composite graft without vascular anastomosis. In the third part of the study, penis composite graft was transplanted between
LBN donors and LEW recipients under tapered dose of CsA monotherapy. Graft survival was monitored by daily observations, somatosensory evoked potentials, histological examination and microangiography to assess transplant viability (Figure 1).
Figure 1. Design of the transplantation procedure
Results:
All vascularized isotransplants and allotransplants survived without signs of acute or chronic rejection over 200 days whereas all nonvascularized grafts underwent
necrosis at 7 days post-transplant (Figure 2). Somatosensory evoked potential evaluation tests confirmed that starting at day 60 post-transplant, stimulation of the glans
of the transplanted penis revealed cortical responses recorded in the somatosensory cortex of the recipient rat. Microangiographic evaluation of the transplanted penile
tissue with lead-oxide gelatin mixture demonstrated well preserved vascular territories of the transplanted penile allograft. Histological evaluation confirmed that there
were no signs of rejection. Besides it was observed on the histological slides that the artery of the urethral bulb, cavernous structures of the corpus spongiosum, the
dorsal penile arteries and the other small arterial branches were filled with the lead-oxide gelatin mixture which was infused via intraarterial route.
Figure 2. Allotransplant on 200th post-transplant day (rerouted penis of the recipient to the scrotum(p), penis allotransplant(pa)).
Conclusions:
This study confirmed feasibility of new penile allograft transplantation model. Long-term (200 days) survival without signs of rejection was achieved on tapered
dose of CsA monotherapy. The sensory function of penile transplant was confirmed by somatosensory evoked potentials. Finally, a new microsurgical technique
of neurovascularization of penile transplant by direct artery-to-corpus spongiosum anastomosis was introduced.
178
Efficacy of In-Vivo Induced Chimeric Cells Used as a Supportive Therapy on Skin Allograft Survival
Erhan Sonmez, MD; Aleksandra Klimczak; Maria Siemionow; Cleveland Clinic
Introduction:
A novel supportive immunotherapy with in-vivo created chimeric cells is introduced and tested in vascularized skin allograft transplants under 7day ·‚-TCR/CsA immunodepletive protocol.
Chimeric animals were created between major histocompatibility complex mismatch ACI(RT1a) donors and Lewis(RT1l) recipients. In the first step of chimeric animals creation ten intraosseus BMTs (100x106) were performed between ACI donors and Lewis recipients, under 7 day ·‚-TCR/CsA protocol. At day 7 post-transplant donor/recipient (RT1a/RT1l) chimeric cells were harvested from the bone marrow compartment of chimeric animals using MACS-sorting technique. In the second part of the study
20 vascularized groin flap transplantations were performed between ACI donors and Lewis recipients in 4 groups (n=5/group). Group 1 was composed of isotransplantations between Lewis rats. Groups 2 and 3 received no treatment after vascularized skin allotransplantation, but Group 3 was supported with intraosseus transplantation
of chimeric cells. Group 4 and 5 received 7 day ·‚-TCR/CsA protocol and Group 5 was additionally treated with intraosseus chimeric cells transplantation. (Table 1).
Recipients were observed for flap viability, signs of rejection and graft-versus-host disease on a daily basis.
Results:
All transplants in the isotransplantation group (Group 1) survived indefinitely. The longest graft survival without immunosuppression in the allograft rejection group (Group
2) was 8 days (mean:7.0±0.70), followed by 9 days (mean:7.8±0.83) in chimeric cell therapy group without immunosuppression (Group 3), 17 days (mean:15.4±1.14)
in 7 day ·‚-TCR/CsA protocol without chimeric cell therapy group (Group 4), and 28 days (mean:23.60±2.96) in immunosuppression with chimeric cell therapy group
(Group 5). The survival was significantly higher in group 5 compared to all other experimental groups (p<0.05).
Conclusions:
In this study we have introduced a novel supportive therapy for vascularized skin allograft tarnsplantation and we have proved that skin alografts are rejected slower when
they are supported with the simultaneous transplantation of in-vivo created donor/recipient chimeric cells without the need for recipient conditioning.
Tables:
Groups
Supportive therapy
Immunosuppression
Days of survival
Survival (Mean±SD)
(
Group 1
Isotrans)(n=5)
No Chimeric
Cell Injection
No Tx
Indefinite
Indefinite
(
Group 2
Alotrans)(n=5)
No Chimeric
Cell Injection
No Tx
6,7,8,7,7
7.0±0.70
(
Group3
Alotrans)(n=5)
Intraosseus
Chimeric Cell Inj.
(10x106)
No Tx
8,9,7,8,7
7.8±0.83
(
Group 4
Alotrans)(n=5)
No Chimeric
Cell Injection
7 day‚-TCR/CsA
17,14,15,16,15
15.4±1.14
Group 5
Intraosseus Chimeric
7 day‚-TCR/CsA
22,24,20,28,24
23.6±2.96
Table 1: The design of the groups and the survival times of the vascularized skin allografts are presented.
Superficial Inferior Epigastric Vessels in the Massive Weight Loss Population: Implications for Breast Reconstruction
Institution where the work was prepared: University of Pittsburgh, Pittsburgh, PA, USA
Jeffrey Gusenoff, MD; Devin Coon; Carolyn De La Cruz; J. Peter Rubin; University of Pittsburgh
Background:
Breast cancer risk and reconstructive options after massive weight loss (MWL) are undefined. Utilization of the resulting pannus for autologous reconstruction is possible,
with one option being the superficial inferior epigastric artery (SIEA) flap. Large SIE vessels have been observed in MWL patients during abdominal contouring procedures but their anatomical features have not been assessed.
Methods:
32 consecutive MWL patients undergoing abdominal contouring had their SIE vessels measured intraoperatively to assess correlation with BMI indices and pannus weight
using appropriate statistical analyses.
Results:
64 hemi-abdomens were assessed. Mean age was 46 ± 9.8 years. Mean MaxBMI was 49.5 ± 8.3, CurrentBMI was 29.6 ± 6.0,??BMI was 19.9 ± 5.6 and mean pannus weight was 3338.4 grams. Mean artery size was 1.7mm and mean vein size was 2.9mm. 32/62 (52%) of hemi-abdomens had a usable vessel (?1.5mm). MaxBMI
was related to the overall presence of an SIEA (p=0.009) or usable artery (p=0.04) while both CurrentBMI and MaxBMI were related to superficial inferior epigastric vein
(SIEV) size (p<0.001). Pannus weight was correlated to SIEV and SIEA size(p<0.001)and strongly correlated to CurrentBMI (r=0.78)and MaxBMI (r=0.46).
Conclusion:
The SIE vessel system is commonly present in MWL patients. BMI prior to weight loss is the strongest predictor of SIEA presence and usability. When MWL patients present for
breast reconstruction, careful patient selection along with weight loss history and assessment of pannus size may aid in determining the likelihood of using the SIEA flap.
A Prospective Study of Donor Site Morbidity After Anterolateral Thigh Fasciocutaneous and Myocutaneous Free Flap Harvest
Matthew M. Hanasono, MD; Roman J. Skoracki; Peirong Yu; The University of Texas M. D. Anderson Cancer Center
Background:
The anterolateral thigh free flap is a versatile flap that may be harvested as a fasciocutaneous perforator flap or as a myocutaneous flap by including variable amounts
of the vastus lateralis muscle. We sought to determine the donor site morbidity associated with both types of flap dissection.
Methods:
Between July 2005 and April 2008, the authors performed reconstructive surgery after oncologic resection with an anterolateral thigh free flap in 216 patients with a mean age of 59
years. Complications and donor site function, including loss of sensation, range of motion, lower extremity weakness or instability, and level of activity, were evaluated prospectively.
Results:
Variable amounts of vastus lateralis muscle were harvested with the flap in this series: 25% included no muscle, 38% included minimal muscle, 33% included the superficial half of the muscle, and 4% included the entire muscle. The motor nerve to the vastus lateralis muscle was spared during dissection of the flap pedicle in 78% and but
required division in 21% (13% were repaired and 9% were not repaired). The average flap width was 7.8 cm (standard deviation: 1.8 cm, range: 4.0 to 10.0 cm) and
the average flap length was 21.4 cm (standard deviation: 6.0 cm, range: 8.0 to 30.0). In all cases, an equivalent amount of fascia was included with the flap. Primary
closure of the donor site was performed in 85% of patients and skin graft closure was required in 15%. The mean length of follow-up was 6.5 months. The rate of donor
site complications was 11%. The complications included seroma (5%), wound dehiscence (2%), hematoma (1%), infection (1%), neuroma (1%), and partial skin graft loss
(1%). Eighty-four percent of patients reported a sensory loss in the distribution of the lateral femoral cutaneous nerve. No patient experienced a decrease in range of
motion. Weakness or instability was reported by 8% of patients at their initial postoperative visit, but resolved in all patients within 6 months. All patients regained their
preoperative level of activity.
Conclusions:
The anterolateral thigh free flap is associated with a low rate of complications and functional morbidity. Even when the motor nerve to the vastus lateralis is divided, or
substantial amounts of thigh fascia or vastus lateralis muscle are included in the flap design, all patients return to their preoperative level of function.
179
The Free Vastus Lateralis Muscle Flap: The Ideal Reconstruction of Traumatic Lower Extremity Wounds
Elizabeth M. Kim, MD; Joseph M. Serletti, MD; Liza C. Wu, MD; University of Pennsylvania
Background:
The goals of distal lower extremity wound reconstruction are to provide adequate soft tissue coverage with good contour with as little donor site morbidity as
possible. The free rectus abdominus and ALT flap have been described for free flap lower extremity reconstruction. The purpose of this study is to examine the
use of the vastas lateralis muscle for lower extremity limb salvage. Our operative protocol is unique in that it includes the application of a VAC dressing over a
skin-grafted vastus lateralis muscle flap to reduce the edema and congestion that often complicates lower extremity free flap reconstruction. In our experience,
with this protocol, the free vastus lateralis muscle flap is the ideal free flap for lower extremity wound reconstruction.
Methods:
We performed a prospective study of 11 patients presenting for lower extremity reconstruction secondary to trauma. All were reconstructed using an ipsilateral free vastus lateralis flap with STSG followed by a VAC dressing (removed on POD 5). Implantable Cook Doppler was used for flap monitoring. Photos were
taken at 2 and 6 months post-operatively. Patients were asked to rate his/her result in terms of return to activities, pain, donor site morbidity, and contour of
reconstructed site. Complications such as flap failure, thrombosis, infection, seroma, and hematoma were recorded.
Results:
Average length of follow-up was 6 months. Reconstruction was performed on average 27.2 days after injury. All wounds were culture positive pre-op and at
6 months were infection free. There was 1 superficial abscess and 1 donor site hematoma. 1 flap failed necessitating debridement and a second flap. There
have been no revisions. All patients had a small area of persistent numbness in the lateral thigh. There were no complaints of leg weakness. All patients were
ambulatory at 6 months.
Conclusion:
There are few accounts in the literature of the free vastus lateralis muscle flap, in our opinion, the ideal free flap for lower extremity wound reconstruction. The
vastus can be harvested sparing the motor nerves of the quadriceps and can be tailored to fit the wound sparing the majority of the muscle. Its pedicle is long.
Limiting the operative sites to the ipsilateral leg allows the uninjured leg to be used post-operatively for weight-bearing and transfer. Our early experience using
the ipsilateral free vastus lateralis flap and VAC demonstrates successful lower extremity reconstruction with little donor site morbidity, low complication rate,
and good lower extremity contour.
Prospective Analysis of Perioperative Medical Complications in 300
Consecutive Head and Neck Microvascular Reconstructions
Daniel Alam, MD1; Michael Nuara, md2; Risal Djohan1; (1)Cleveland Clinic Foundation, (2)Cleveland Clinic
The reliability of free flaps has been well established, but systematic data collection on outcomes and complications of patients undergoing these procedures is less
available. We report our experience of 300 consecutive microvascular head and neck reconstructions after ablative oncologic procedures. Data from variables including preoperative comorbidities (cardiac history, diabetes, radiation therapy, etc), intraoperative factors (surgical time, blood loss, etc), and postoperative complications
were collected in a comprehensive database in a prospective fashion. There was one microvascular failure (0.3%) with 5 additional cases of partial flap loss (1.7%).
A thorough collection of all adverse postoperative cardiac and pulmonary events as well as hospital acquired processes such as DVT formation, pulmonary embolism,
and acquired infections was completed. The association of these postoperative outcomes to the preoperative and intraoperative variables was then analyzed. The most
significant complications were 5 postoperative myocardial events (two symptomatic MI's and three asymptomatic troponin elevations) and four cases of pulmonary
embolus documented by spiral CT scan examination. The majority of these events were not associated with preoperative cardiopulmonary histories. Some form of
minor/major medical and wound complication unrelated to flap survival occurred in 21% of the patient population. The most significant preoperative factor predicting adverse postoperative outcomes was pre-surgical radiation therapy. A bimodal distribution in complications was seen with patients either having zero/one complication or multiple complications (>3). This finding highlights the fragility of this clinical population and the tendency for patients who suffer a few medical complications to advance to multiple adverse clinical outcomes. While successful microvascular tissue transfer is commonplace, the data from this report will hopefully better
elucidate the potential systemic complications that are seen in this frail patient population.
Tertiary Breast Reconstruction after Failed Implant Reconstruction Using Autologous Free Flaps
Institution where the work was prepared: Dep. Plastic Surgery, Erasmus MC, Rotterdam, Netherlands
Marc A.M. Mureau, MD, PhD1; Tim H.C. Damen1; Stefan O.P. Hofer, MD, PhD, FRCS(C)2; (1)Erasmus University Medical Center Rotterdam, (2)University
Health Network, University of Toronto
Purpose:
Although breast implant reconstruction is generally propagated as a simple method, aesthetic outcome can be inadequate due to implant displacement or
(painful) capsular contracture requiring implant replacement or removal in up to 50% of patients. Literature on outcome of conversion of failed breast implant
reconstructions into autologous tissue reconstructions (tertiary breast reconstruction) hardly exists. The purpose of this study was to evaluate complications and
outcome of tertiary breast reconstructions using autologous free flaps.
From June 2001 to December 2007, 71 tertiary breast reconstructions were performed in 48 patients using autologous free flaps. All patient data were
obtained retrospectively from a structured database in which patient characteristics, surgical data, and complications had been collected prospectively. A studyspecific questionnaire was used to evaluate patient satisfaction and physical complaints.
Results:
Mean age at operation was 49 years (32 to 62 yrs). There were 26 unilateral and 22 bilateral reconstructions. DIEP flaps were most commonly performed (57
times), followed by msTRAM flaps (9), TMG flaps (4), and one SGAP flap. Mean flap weight, ischemia time, and total operation time were 684 grams (295
to 2250 grams), 77 minutes (35 to 156 minutes), and 7.5 hours (4 to 14 hours), respectively. There were 7 flap complications (9.9%) and 3 abdominal complications (6.3%) leading to re-operations. Three flap hematomas were evacuated, three venous anastomoses were revised and in one flap a marginal necrosis was excised. There was one total DIEP flap loss which was salvaged with a free SGAP flap leading to a flap survival rate of 98.6%. Ten patients had no
additional operations to improve the end result, 24 patients underwent one extra procedure, 8 patients two, and five women three or more, leading to 1.6
additional operations per patient. Additional operations at the acceptor-site were nipple reconstruction (22x), excisional shaping (15x), lipofilling (8x), liposuction (3x), and excision of fat necrosis (2x). Seven contralateral breasts had to be reduced to correct asymmetry. Additional procedures at the donor-site were
scar revision (17x), liposuction (5x), and abdominal hernia repair (4x). Overall patient satisfaction was very high, with a mean satisfaction of 8.5 out of 10.
Preoperative pain and tightness improved in all patients.
Conclusion:
Tertiary breast reconstruction using autologous free flaps is a feasible and reliable procedure leading to high patient satisfaction with minimal physical complaints. To reach an optimal aesthetic end result 1.6 additional operations were needed.
180
Patient Preferences for Breast Reconstruction: A Discrete Choice Experiment
Institution where the work was prepared: Erasmus University Medical Center, Rotterdam, Netherlands
Tim H.C. Damen1; Esther W. de Bekker - Grob, MSc2; Marc A.M. Mureau1; Stefan O.P. Hofer, MD, PhD3; Marie-Louise Essink-Bot, MD, PhD4; (1)Erasmus
University Medical Center Rotterdam, (2)Erasmus University Medical Center, (3)University Health Network, University of Toronto, (4)Academic Medical
Center, University of Amsterdam
Introduction:
Individual patients' preferences are important determinants in the decision on a specific type of breast reconstruction (BR), complementary to other patient-related factors (e.g., medical history, body habitus) and surgeon-related factors (e.g., expertise, experience). Understanding women's motivational factors underlying such a decision can contribute to further improve patient information and to develop demand-led healthcare. We therefore explored women's preferences
for three BR modalities and the determinants of these preferences in a formal discrete choice experiment (DCE).
Four hundred women who had undergone a mastectomy between

ASRM - American Association for Hand Surgery

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