The evaluation of our results from the use of transscalen block in shoulder surgery.

During September 2008 – March 2009, in our institution 25 patients underwent different types of shoulder surgery. Fifteen patients were male and ten female with mean age 56 y.o. Shoulder pathology included fractures, rotator cuff tears, subacromial decompression. Two of the patients received general anaesthesia because of anatomic variations to the neck and the rest twenty three of them underwent a transcalen block as method for anaesthesia. For the block all the patients received 20 ml Naropeine 7.5% and 10 ml NaCl 0. Two out of twenty three patients received, during the beginning of surgery, general anaesthesia because of pain. There were no other complications, regarding the anaesthesia, during the surgery. The postoperative analgesia was 8.5 hours in average. None of the patients received postoperatively any strong analgetics.

We believe that the use of transcalen block is a safe and secure method of anaesthesia for the shoulder surgery with excellent analgetics results.

Purpose: The aim of this study was to investigate the results of end-to-side neurorraphy of the common peroneal nerve (CPN) to the tibial nerve (TN) in rats, after administration of bFGF or NGF. Materials: Five (5) groups of adult male Wistar rats, each comprising 25 animals, were studied:

End-to-side neurorraphy (4 groups) Group A bFGF (20ng) Group B NGF (25ng) Group C (normal saline) Group X [bFGF (20ng) + NGF (25ng)]

All experimental procedures were performed under the supervision of a veterinarian and were prospectively approved by the Animal Experimental Ethics Committee.

Methods: In groups A, B and X, the 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. Sub sequently, a total volume of fifty microliters (50μl) of the corresponding solution of growth factor(s) was administered in each case beneath the epineurium, proximal to the CPN/TN coaptation site, with the aid of a microsyringe. The same surgical procedure was carried out in group C (positive control group), as well, but an equal volume (i.e. 50μl) of normal saline was administered instead. Finally, in each of the animals of the remaining group G, both the proximal and the distal stump of the CPN were carefully sutured into the neighbouring muscles; hence, the latter would constitute a negative control group, thanks to the resulting atrophy of the CPN – innervated musculature. 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 right CPN was operated upon; the contralateral (left) CPN remained intact, thus serving as control. Euthanasia was achieved by means of intracardiac administration of high – dose sodium pentobarbital.

Results: The evaluation of the outcome four (4) months postoperatively was based on clinical examination, walking-track analysis, electromyographic and histomorphometric studies. Our data indicate that the administration of the growth factors under investigation has a favorable effect on the outcome of CPN repair; the administration of bFGF, in particular, seems to improve the results of terminolateral neurorraphy in the time span studied.

Conclusions: In rats, CPN repair via end-to-side neurorraphy to the TN can be enhanced by the administration of bFGF or NGF.

Backround: To present the results in a series of patients with complex distal radius fractures featuring comminution of the articular surface and the metaphysis in whom we used a volar as well as a dorsal approach in order to control the axial alignment and reconstitute the articular surface.

Material: There were sixteen patients with an average age of 26 years. All the fractures were classified as C3 according to AO Universal Classification. All the patients underwent an open reduction and internal fixation through a dorsal as well as a volar approach. Secondary operations were necessary for five patients.

Results: The average extension was 56, the average flexion was 51, pronation 70 and supination 76. The grip strength was 75% of the contralateral hand. The average ulnar inclination was 20°, 3 dorsal inclination, 0.9 mm ulnar variance and 1 mm articular incongruity. Three patients had radiological signs of radiocarpal arthritis. Excellent or good results achieved in the 40% of the patients according to the system of Green and O’Brien

Conclusion: The combination of dorsal and volar approach it is necessary for the carpus to be well aligned in order to achieve stability and give the opportunity for early mobilization. Sometimes additional operations are necessary.

Aim: To retrospectively review the results of the use of adductor digiti quinti flap in failed cases of primary carpal tunnel tunnel release. The concept under this procedure is to provide a highly vascularised bed for axonal regeneration.

Material: Twenty cases of failed carpal tunnel release included in the study. The average age of patients was 43 years. There were thirteen female and five male patients. In two cases, one male and one female the procedure performed bilaterally.

All patients had a repeat of release ading a neurolysis of the median nerve. The adducor digiti quinti flap was dissected up to its neurovascular bundle and flipped over..

Results: In thirteen cases the procedure was successful as this was detected objectively and subjectively. In four cases the situation was unchanged and in three a revision surgery required for decompression of the nerve. Complex regional pain syndrome developed in three cases.

Conclusion: Although postoperative healing and rehabilitation time is lengthy due to more extensile dissection, pain relief, motor and sensory improvement, and hand dexterity justify the procedure.

Introduction: Noncontiguous fractures of the tibial diaphysis and ipsilateral ankle is an uncommon entity. The aim of this study is to highlight the unique fracture pattern with emphasis on the necessity for surgical treatment. Material: There were 17 patients with an average age of 42 years, who sustained ipsilateral, noncontiguous fractures of the tibia and ankle. All but two fractures were closed. The level of the tibia fracture included midshaft (two), middle-distal third (ten), distal third (five). Eleven ankle fractures were classified as Weber B, five as Weber C and one Pilon. Two fractures were treated by cast immobilization, eleven with internal fixation of both fractures and four with a combination of internal and external fixation. Seven fractures were treated initially in long leg casts, but each required surgical intervention to control fracture alignment. Results: The average follow up was twenty-three months. The non-operatively treated fractures resulted in a malunion and decreased ankle mobility. Of the cases managed operatively, nine had complete structural and functional recovery; two patients regained 70% of ankle mobility and one developed post-traumatic ankle arthritis. Discussion: The resulted experience from the treatment of these injuries showed their extremely unstable nature. It has been our experience that the nature of the forces acting upon the fragments usually underestimated since reduction of one fracture displaces the other. Furthermore if acceptable reduction is achieved by closed means, progressive slippage of the fragments occurs. We believe that stable fixation of both fractures should be the treatment of choice

We reviewed 40 patients who underwent V-Y skin flap reconstruction following distal fingertip skin loss.Of the patients 35 were males and 5 females with an average age of 35 years at operation.Surgery was performed as an emergency in all patients.In all cases a single digit was involved.The majority of the injuries were transverse amputations.Mean advancement of the flap was 12 mm.At the follow-up evaluation (mean 2 years),8 patients complained of pain (2 with functional impairment),15 complained of cold intolerance,and 5 had nail deformities.Sensibility of advanced skin was normal in 28 cases,while two-point discrimination averaged 7 mm.This discrimination was virtually identical to contralatertal digits in 25 of the cases.Overall 28 patients were satisfied with their results,while the rest of them were mildly displeased,either with the functional impairment or with the appearance of the involved digits.

Evaluations of 32 adults with 50 complete digital nerve injuries were made more than 1 year after surgery. Twenty patients were men and 12 were women. The mean age of the patients at operation was 30 years. The mean follow-up time was 2 years. Patients were excluded if they had a skin graft, had a second surgery after digital nerve repair or graft, were diagnosed with diabetes, had additional proximal nerve injuries, had postoperative infections, had a complete digital amputation or had a dorsal digital nerve injury. According to the initial injury mechanism, patients were classified into three grades : grade I was defined as a sharp, clean-cut injury, grade II was mild crush and grade III was a severe crush injury. Overall, there were 30 primary digital nerve repairs, 12 secondary repairs and 8 secondary nerve grafts. Moving and static two-point discrimination was determined on both lateral aspects of the injured and contralateral uninjured digits. Digits with primary repairs in mild or severe crush injuries had significantly worse two-point discrimination compared with digits that had a primary repair of a simple laceration. Futhermore, in mild crush injuries, digits with secondary nerve grafting had significantly better results than those with primary repair. Patients under 30 years age had better results than those over 30 years. These results support the hypothesis that better recovery is obtained if tension is avoided at the nerve repair site in mild crush injuries.

Instability of the thumb trapeziometacarpal joint is a major factor in the cause of degenerative disease. Surgically stabilized joint should be subject to less shear forces and hence, will be less likely to develop degenerative changes. The results of volar ligament reconstruction were assessed in 12 patients (8 men- 4 women). The average age at surgery was 35 years. All thumbs were radiographic stage I. All had failed conservative treatment with splinting and anti-inflammatory medication. Operativelly a strip of Flexor Carpi Radialis tendon was used for ligament reconstruction according to the technique described by Eaton, Glickel and Littler. The follow-up period averaged 7 years. At final follow-up 8 thumbs were stage I, 3 were stage II, and one was stage III. Ten patients were at least 90 % satisfied with the results of the surgery and only two had symptomatic thumb basal joint.

Between 1988 and 1998, a total of 12 patients (6 men and six women, of average age 36 years) underwent surgery for schwannoma of the peripheral nerves of the upper extremity. The incidence according to the involved nerve was analyzed and the follow-up results and complications after surgical treatment were reviewed. The median nerve was most frequently involved (6 cases), followed by the ulnar nerve (4 cases) and the radial nerve (2 cases). The average duration of symptoms was 2 years (3 months-8 years). Pain or painful paresthesias were usually the main complains. None of the patients suffered from Recklinhausen’s disease. Magnetic resonance imaging is the preferred exploration technique, particularly useful in case of deep tumor. EMG studies were carried out in all patients. Preservation of nerve continuity is the underlying goal of the therapeutic strategy. Marginal excision was performed in all cases. The tumors were extricable displacing the nerve fiber bundles without penetrating into the bundle itself and it was possible thus to be resected without interrupting the nerve continuity. Postoperatively, 7 patients were pain free, while 5 improved. Neurological deficits were favourably influenced by the operation. Out of 4 patients with motor deficits 3 had complete and 1 had partial recovery. Three out of 6 patients with sensory deficits had complete recovery, 2 remained unchanged, while 1 worsened. One patient developed new motor and another one new sensory deficits. New deficits developed predominantly in patients with large tumorsor longstanding symptoms. There was no reccurence or malignant transformation until the average of 52 months of follow-up.

We reviewed the functional outcome of cominnuted intraarticular fractures of the distal humerus managed with internal fixation with plates and screws. 15 patients (10 men-5 women) were reviewed over a mean of 29 months postoperatively. The age of the patients at operation ranged from 18 to 72 years. Patients were treated within 7 days of injury, using a posterior approach,with or without olecranon osteotomy and with anterior transposition of the ulnar nerve. Bone grafting was used in 7 cases in addition to internal fixation. Postoperative mobilisation was prompt in all patients,who were meticously reviewed for : 1)Function of the upper extremity,with the aid of the scale of DASH (Disabilities of the arm,shoulder and hand), 2)Ulnar nerve (pain, sensitive and movement dissability, functionality), 3)Range of elbow motion, 4) strength of the muscles controlling the elbow, wrist and hand. 5)Post-operative radiographic appearance, 6)Subjective evaluation, 7)Complications. All the patients were satisfied with the outcome of the operation,as well as with the activities which could postoperatively be undertaken. The mean range of motion for elbow (flexion-extension) was 118° in average,while muscle strength for elbow motion was moderately reduced. No case of ulnar neuropathy was observed. On the other hand postoperative complications were considerably frequent, yet they were mild and subsided eventually without further operation.