Donor Limbs Research Articles

Effect of non-vascularized fibular harvest on the donor limb: radiological evaluation at a mean follow-up of twelve point eightyears.

The study is aimed at evaluating the long-term (at a minimum follow-up of 10years) impact of non-vascularized fibular harvest on the donor limbs. There were 27 donor limbs (n = 19 children) available for retrospective radiological review. The graft was obtained bilaterally in eight patients. The following parameters were evaluated in the follow-up radiographs: continuity/non-continuity of fibular regenerate, width of the regenerated fibula, distal fibular station, medial proximal tibial angle, posterior proximal tibial angle, lateral distal tibial angle (LDTA), anterior distal tibial angle, and tibia diaphyseal angulation (interphyseal angles). For analysis and comparisons, the donor limbs were compared to the healthy limbs (controls) of the children with unilateral harvest. Additionally, the impact of continuous and non-continuous fibular regeneration was separately analyzed. The mean child's age at the time of fibular harvest was fouryears. The mean follow-up was 12.8years. The fibula was found regenerated in continuity in 22 limbs of 15 children (81.5%). When analyzed as a combined group (both continuous and non-continuous fibular regenerations), all the donor limb radiological parameters matched those of healthy limbs except LDTA (p = 0.04). In the subgroup analysis between non-continuous and continuous fibulae, significant abnormalities were again obvious in LDTA (p = 0.0001). The non-continuous fibulae were significantly lesser in width. All limbs with non-continuous fibular regeneration manifested ankle valgus. The non-vascularized fibula emerged as a relatively safe procedure in the long term with minimal affections of the knee, ankle, or tibial anatomy when longitudinal integrity of fibula was restored. The non-regenerations of the fibula may be prone to developing ankle valgus.

Emerged donor limb growth morbidity and malalignment after combined ipsilateral tibial and fibular cortical harvest graft in children. Early follow-up report.

The quantity of bone grafts required in certain pediatric conditions is sometimes substantial. This retrospective study details the radiological changes occurring in the donor leg and ankle following the simultaneous harvest of large diaphyseal cortical grafts from the tibia and fibula in 14 children (16 legs). The following preoperative and follow-up radiological parameters were measured and compared for donor legs: the longitudinal continuous regeneration of fibula, distal fibular station, medial proximal tibial angle, lateral distal tibial angle, posterior proximal tibial angle (PPTA), anterior distal tibial angle and interphyseal angle (tibia diaphyseal angulation) in both coronal and sagittal planes. Additionally, the impact of fibular regeneration in combined harvests was separately analyzed. Children were operated at the mean age of 52 months. Mean follow-up of 25.2 months was available. At follow-up, the donor tibia healed completely in all legs whereas fibular regeneration was complete only in 10 legs (62.5%). At follow-up, ankle valgus was present in 6 out of 16 legs (37%) and tibia valga increased in all legs except one (94%). Procurvatum was present in 7 legs. The fibular nonregeneration group was prone to ankle valgus deformity ( P = 0.014), valgus angulation of tibial diaphysis ( P = 0.0076) and lower mean PPTA ( P = 0.026) when compared to the regenerate group. There was a complication of stress fracture in one donor tibia. Combined tibial and fibular harvest is a major surgical undertaking in children. The donor limbs have their share of complications postharvest, more so when the fibula remains nonregenerated. Serial monitoring of donor sites is emphasized.

Nonvascularized fibular harvest in children: impact on donor limbs.

Nonvascularized fibular graft is commonly used in children. We investigated periosteal intactness, proportion of harvested fibula and the distal remnant for their association to regeneration and development of ankle valgus in 25 donor limbs (n = 18 patients). The fibulae were harvested from healthy legs with all possible care to preserve periosteum. Intraoperatively, periosteal breach and length of graft obtained were recorded. Follow-up radiographs at 6 months documented lateral distal tibial angle, fibular station, and longitudinal continuous regeneration of fibula in the donor limb. Limbs with and without regeneration/ankle valgus were matched for proportion of harvested length and distal remnant, respectively. Odds ratios for periosteum breach versus nonregeneration and nonregeneration versus ankle valgus were additionally calculated. The average harvest length and distal remnant were 15.1 and 4.5 cm, respectively. The periosteum intactness was maintained in 18 (72%) limbs. At 6 months follow-up, regeneration of fibula was present in 15 (60%) limbs. The postharvest-acquired ankle valgus was present in five limbs (24%). There was almost 2.5 times increased likelihood of nonregeneration, if periosteum was breached. The odds ratio for nonregeneration versus regeneration to the development of ankle valgus stood at 12 ( P = 0.0483). Periosteal breach increased the odds of nonregeneration of harvested fibula. The length of harvested segment did not appear to have significant influence on regeneration nor did distal segment on ankle valgus. The nonregeneration of fibula, however, made the limb prone to ankle valgus.

Donor site changes in early months following nonvascularized fibular harvest in children: a prospective radiological analysis.

The exact timing of non regeneration and ankle valgus in post fibular harvest donor limbs remain elusive. The study examined the serial radiographs post harvest to better understand the transitions occurring in the ankle and leg region. We specifically focused on the noncontinuity of fibular regenerate, lateral distal tibial angle (LDTA), fibular length (fibular/tibial ratio, F/T ratio) and fibular station in the donor leg. Completeness of longitudinal fibular regeneration was documented at 6 months and accordingly two groups, with (R+) and without complete longitudinal regeneration (R-), were available for comparisons. There were 25 fibular harvests in 19 patients. The longitudinal regenerate was complete in 14 limbs (56%) (R+ group) at 6 months. The average LDTA at 6 months did not differ significantly from preoperative values. The F/T ratio decreased immediately postoperative and the trend remained sustained till 6 months. Malhotra grade corresponded inversely to F/T ratio. There was insignificant intra or intergroup affection of LDTA in R+ and R- groups over initial 6 months. The F/T ratio in R+ group recorded a downward trend till 3 months but remained static thereafter. Malhotra grades comparisons between R+ and R- revealed significant differences only at 6 months. Fibular length (F/T ratio) was found to be the critical indicator of regeneration. For the nonregenerates, ratios deteriorated significantly by 3 months. Malhotra station corresponded to changes in fibular length, although it was less quantitative. The secondary changes in lower tibia may not manifest till 6 months.

Patient-Reported Outcomes after Fibula Free Flap Harvest: A Pilot Study.

Patient-reported outcomes regarding donor-site morbidity and quality of life for the fibula free flap in head and neck reconstruction patients have not been studied. The authors reviewed and identified patients who had undergone head and neck reconstruction using a fibula free flap (2011 to 2016). Patients were assessed via physical examination and two patient-reported outcomes questionnaires: the Foot and Ankle Outcome Score (score range, 0 to 100) and the Pain Disability Questionnaire (score range, 0 to 100). Quantitative data were analyzed with appropriate statistical tests. Semistructured interviews exploring donor-site challenges were performed and analyzed using thematic analysis. Seventeen patients agreed to participate. Their mean age was 62 years (range, 41 to 81 years). Mean follow-up was 38 months (range, 12 to 65 years). Mean perceived level of function compared to baseline was 67 percent. Mean scores for the Foot and Ankle Outcome Score subscales were 84.6 (pain), 80.5 (symptoms), 86.7 (activities of daily living), 67.7 (sport), and 65.6 (quality of life). The mean Pain Disability Questionnaire score was 26.3 (mild/moderate perceived disability). Higher perceived level of function was associated with higher Foot and Ankle Outcome Score values (pain, symptoms, and activities of daily living, p < 0.05). Donor limbs had decreased range of motion and manual muscle testing scores compared with their contralateral limbs (p < 0.05). Lack of ankle support and balance, resulting in limitations and aversions to daily and sporting activities, were the most common themes regarding donor-site challenges. In conclusion, patients who have undergone fibula free flap harvest struggle with ankle support and balance and face functional difficulties that have an impact on their quality of life. Multidisciplinary approaches for targeted rehabilitation after fibula free flap harvest should be explored to determine the impact on patients' quality of life.

Donor-recipient matching in hand transplantation: a comparison of anthropometric measurements, 3-dimensional virtual models and printed epitheses.

Donor-recipient matching in hand transplantation remains challenging. The usefulness of three-dimensional (3-D) virtual models and printed epitheses were compared with measurements on cadaveric extremities to evaluate the most accurate method of donor-recipient matching for allograft procurement. Ten anthropometric measurements were recorded from 12 human cadaveric upper extremities and matched to printed epitheses and 3-D virtual models. Five circumferential and two longitudinal measurements obtained an intra-class correlation of >0.75 with all three methods, with the Kaplan (0.973) and wrist circumferences (0.942) achieving the highest concordance. Measurement on cadaveric specimens was the most reliable method. Using different combinations of donor hand and recipient forearms, a series of 72 virtual transplantations were then created, and their compatibility rated by ten transplant surgeons. The results confirmed that anthropometric measurements, obtained directly from potential human donor limbs and based on wrist circumference as the primary parameter, provide the best and most clinically relevant donor-recipient match.

Four-Year Follow-Up of the World's First Pediatric Bilateral Hand-Forearm Transplants: Do They Grow as Expected?

In 2015, the first bilateral pediatric hand-forearm transplant was performed in an 8-year-old boy. The growth rate of the transplanted upper extremities was unknown at the time. Forearm and hand radiographs were obtained annually. Radius and ulna measurements were performed by multiple coauthors and mathematically normalized using a standardized methodology. The Greulich and Pyle atlas was used to estimate hand bone age. From July of 2015 to July of 2019, unadjusted bone length (metaphysis to metaphysis) increased 38.8 and 39.6 mm for the left radius and ulna, and 39.5 and 35.8 mm for the right radius and ulna, respectively. Distal physes of the donor limbs increasingly contributed to overall bone length relative to proximal physes. Normalized growth between the two limbs was statistically similar. At each annual follow-up, the bone age increased by 1 year. Successful pediatric hand-forearm transplantation offers the advantage of growth similar to that of nontransplanted pediatric patients. The transplanted distal physes contributes more to the overall growth, paralleling normal pediatric growth patterns. Chronologic age parallels the increase in bone age. Therapeutic, V.

Outcomes of Arterial Conduits in Vascular Reconstruction After Oncologic Resection of Locally Advanced Pancreatic Malignancies

To determine early and midterm outcomes of various conduit types for visceral artery reconstruction after resection of locally advanced pancreatic malignancies. Retrospective review of all patients who underwent resection for pancreatic malignancy with visceral reconstruction using superficial femoral artery (SFA), great saphenous vein (GSV), splenic artery (SA), cryopreserved allograft, or prosthetic graft (PG) between 2000 and 2019. The SFA donor limbs were revascularized with expanded polytetrafluoroethylene interposition grafts. End points for visceral and donor limb arterial reconstructions are primary and secondary patency, vascular complications, and mortality. Visceral reconstruction for oncologic resection was performed in 57 patients. Reconstructed arteries included proper hepatic (n = 24), common hepatic (n = 17), superior mesenteric (n = 22), right hepatic (n = 5), and left hepatic (n = 2) with multivessel reconstructions performed in 13 patients. Of 57 visceral reconstructions, 30 were performed with autogenous SFA; 27 had no preoperative evidence of peripheral arterial disease. Median follow-up for all patients was 9 months. The 30-day visceral reconstruction complications included pseudoaneurysms in one SFA conduit (requiring gastroduodenal artery coiling and covered stent placement) and one GSV conduit (requiring covered stent placement), thrombosis in one PG conduit and one GSV conduit (both requiring open thrombectomy), and anastomotic bleed from one SA conduit (requiring operative repair). The 30-day SFA harvest donor limb complications included one hematoma, one lymphocele, and one symptomatic edema. Early mortality occurred in three patients including one SA conduit with multiorgan failure, one GSV conduit pseudoaneurysm rupture secondary to pancreatic leak and one SFA conduit of unknown cause. Midterm visceral reconstruction complications included pseudoaneurysm in 6 patients (3 SFA conduits with 2 treated, 3 GSV conduits with all treated), and graft occlusion in 10 patients (3 SFA, 4 GSV, 1 cryopreserved allograft and 2 PG). One patient underwent percutaneous angioplasty for high-grade stenosis of a SA graft. This gave a primary and secondary patency for all visceral arterial reconstructions of 81% and 84%, respectively. Midterm SFA donor limb patency was 100% with median follow-up of 8 months. Late mortality occurred in 19 patients (33%) with 11 cancer-related deaths and 5 of unknown cause or unrelated to the primary cancer. Three late mortalities occurred secondary to mycotic graft pseudoaneurysm ruptures in the setting of bile and pancreatic leaks (1 GSV, 1 PG secondary reconstruction in SFA conduit patient and 1 SFA conduit). This preliminary study suggests that superficial femoral artery can be considered feasible conduit in oncologic reconstructions with low morbidity of the donor limb. Long-term follow-up is needed to identify oncologic and patency-related outcomes.TablePrimary end points by conduit choiceConduitNo. of patientsPrimary patencySecondary patencyMajor early visceral graft complicationsAll-cause mortality, % (vascular-related, %)Median follow-up, months (range)Superficial femoral artery3090%90%n = 1 pseudoaneurysm30 (7)8 (2-39)Cryopreserved allograft988%88%n = 00 (0)4 (1-23)Great saphenous vein838%38%n = 2 (1 pseudoaneurysm, 1 thrombosis)75 (25)11 (0-25)Prosthetic graft667%83%n = 1 thrombosis67 (0)12 (1-107)Splenic artery450%50%n = 1 anastomotic bleed50 (0)26 (1-52) Open table in a new tab

Abstract 46: 4-year Follow-up Of The World’S First Pediatric Bilateral Hand-forearm Transplants: The Growth And Progress Continues

Introduction: In 2015, the first bilateral pediatric hand-forearm transplant was performed in an 8-year old boy. The long-term functional outcomes and growth of transplanted upper extremities was unknown. Methods: Forearm and bone age radiographs were obtained annually. Radius and ulna measurements were performed and mathematically normalized by a pediatric musculoskeletal radiologist (JCN) alongside coauthors (SCA, NM, RK). Greulich & Pyle Atlas was used to estimate hand bone age. Functional testing and patient reported outcomes are reviewed. Results: From July 2015 to July 2019, bone length increased 33 mm and 37 mm for right ulna and radius, 38 mm and 37 mm for left ulna and radius, respectively. Distal physes of the donor limbs increasingly contributed to overall bone length relative to proximal physes, which grew slowly. Normalized growth between the two limbs was statistically similar (p>0.05). At each annual follow-up, the bone age increased by 1-year. Bone healing resulted in normal structure in the transplanted and recipient bone. Motor, sensory and functional independence measures are encouraging. No pain was noted (0) during exercises (0-10 scale). Conclusions: Successful pediatric hand-forearm transplantation offers the advantage of growth similar to non-transplanted pediatric patients. The transplanted distal physes contributes more to the overall growth, paralleling normal pediatric growth patterns. The patient continues to make gains in all domains, functional activities of daily living and grasping.

Donor limb assessment after vascularized groin lymph node transfer for the treatment of breast cancer-related lymphedema: Clinical and lymphoscintigraphy findings

Vascularized lymph node transfer is an established treatment for secondary lymphedema. Different donor sites of lymph node flap have been described. In our institute, vascularized groin lymph node (VGLN) flap is the workhorse flap for treating breast cancer-related lymphedema (BCRL). Potential complications of VGLN flap harvesting include seroma formation, thigh dysaesthesia, and iatrogenic lymphedema. Between August 2013 and June 2016, 30 consecutive patients with a mean age of 60 years underwent VGLN transfer for BCRL. Reverse mapping of lower limb lymphatics with patent blue solution was performed in all cases. The donor limb conditions were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Postoperative lymphoscintigraphy findings and transport indexes were compared between the donor and nonoperated limbs. The mean follow-up period was 22.11 ± 7.83 months. Three (10%) patients developed groin seroma and 18 (60%) patients complained of transient thigh dysaesthesia. There was no clinically detectable donor limb lymphedema. Lymphoscintigraphy was performed at a mean of 13 months after operation. The mean transport indexes of the nonoperated limbs and donor limbs were 2.04 and 3.32, respectively. For the donor limbs, all patients had normal distribution pattern of contrast uptake. No dermal backflow pattern was demonstrated. With good knowledge of groin anatomy and meticulous surgical skills, VGLN flap can be harvested without causing major consequence to the donor limb.

Free flap pedicled with peroneal artery perforator to repair soft tissue defects at hands and feet

Objective To explore the clinical effects of free flap pedicled with peroneal artery perforator in repair of soft tissue defects at hands and feet. Methods From July 2010 to December 2012, 36 patients with soft tissue defects at hands and feet were repaired by free flaps pedicled with peroneal artery perforator. They were 30 men and 6 women, 21 to 50 years of age (average, 32.6 years). Twenty-one pa-tients had skin defects at distal 1/3 dorsum of foot; of the 15 patients with hand soft tissue defects, 8 had skin defects and tendon exposure at dorsum of hand, 3 had skin defects between the thumb and the index finger, and 4 had skin defects and tendon exposure at the palm. The defective areas varied from 3.0 cm×2.0 cm to 8.5 cm×4.0 cm, the flap harvesting area varied from 4.0 cm × 3.0 cm to 10.0 cm × 5.0 cm. the time from injury to operation was from 3 to 78 hours (average, 12.8 hours). Twenty-nine flaps were pedicled with intramuscular perforating branches, and 6 with intermuscular perforating branches. The blood vessels were anastomosed end to end. The function of affected limbs in the 15 cases of hand soft tissue defect was evaluated at the last follow-up according to the criteria by Hand Surgery Society, Chinese Medical Association (HSSCMA); the 21 patients with soft tissue defect of the feet was evaluated according to criteria by Japanese Orthopaedic Association (JOA); the functional recovery of skin sensation in the 36 patients was evaluated according to the criteria by British Medical Research Council (BMRC). Results All the transferred free flaps survived uneventfully. The 36 patients were followed up for 6 to 24 months (average, 11 months). The flaps showed no pigmentation but fine texture, appearance, and wear-resistance. According to HSSCMA cri-teria, the function of affected limbs was excellent in 12 cases, good in 2 and fair in one. According to JOA criteria the 21 patients with soft tissue defect of the feet scored an average of 90.6 points (rang, from 80 to 98 points). According to BMRC criteria, the functional recovery of skin sensation was S3 to S4 in 25 cases, S2 in 9, and S1 in 2. The donor limbs showed no cicatricial contracture or dysfunction. Conclusions Free flaps pedicled with peroneal artery perforator are a good choice for repair of small or middle areas of soft tissue defect at hands and feet, because they are characterized by stable vascular anatomy, proper thickness, no damage to primary artery, slight injury to the donor site, and direct anastomosis. Key words: Surgical flaps; Soft tissue injuries; Hand; Foot

Prevention of edema after coronary artery bypass graft surgery by compression stockings.

Background:Lower limb edema may occur after removal of the saphenous veins in coronary artery bypass graft (CABG) surgery. Compression therapy is often used to prevent postoperative edema.Objectives:The objective of this study was to evaluate the efficacy of medical compression stockings (TED) on the prevention of donor limbs edema and wound complications after CABG surgery.Patients and Methods:In this prospective cohort study, we enrolled 100 patients who underwent elective CABG surgery at Rajaie Cardiovascular Medical and Research Center. The patients were divided into two groups; group A who applied TED stockings regularly (exposure group) and group B who did not apply TED stockings at all or apply it irregularly (no exposure group). The degree of donor limb edema and the differences of the peripheries of calf and thigh before and after the surgery (in 1, 2 and 4 weeks) were recorded and analyzed statistically.Results:The patients' weight (P = 0.02) and the degree of their daily activity (P = 0.002) were the significant factors for the incidence of the donor limbs edema. The incidence and degree of lower limb edema were significantly lower in exposure group 4 weeks after the surgery (P < 0.001). The differences of the periphery of the calf before (at admission time) and after the surgery (in 1, 2 and 4 weeks) between two groups were also statistically significant (P = 0.41, P = 0.39, P = 0.40, respectively). Lower limb wound complications was higher in patients who have peripheral edema in the 4th week of post-CABG (P = 0.09).Conclusions:Regular use of TED stockings may have positive effects on the prevention of donor limb edema (especially higher degrees of edema) and wound complications after CABG surgery.

Segmental motion of forefoot and hindfoot as a diagnostic tool

Segmental motions derived from non-invasive motion analysis are being used to investigate the intrinsic functional behavior of the foot and ankle in health and disease. The goal of this research was to examine the ability of a generic segmented model of the foot to capture and differentiate changes in internal skeletal kinematics due to neuromuscular disease and/or trauma. A robotic apparatus that reproduces the kinematics and kinetics of gait in cadaver lower extremities was employed to produce motion under normal and aberrant neuromuscular activation patterns of tibialis posterior and/or tibialis anterior. Stance phase simulations were conducted on 10 donor limbs while recording three-dimensional kinematic trajectories of (1) skin-mounted markers used clinically to construct segmented foot models, and (2) bone-mounted marker clusters to capture actual internal bone motion as the gold standard for comparison. The models constructed from external marker data were able to differentiate the kinematic behaviors elicited by different neuromuscular conditions in a manner similar to that using the bone-derived data. Measurable differences between internal and externally measured kinematics were small, variable and random across the three axes of rotation and neuromuscular conditions, with a tendency toward more differences noted during early and late stance. Albeit slightly different, three-dimensional motion profiles of the hindfoot and forefoot segments correlated well with internal skeletal motion under all neuromuscular conditions, thereby confirming the utility of measuring segmental motions as a valid means of clinical assessment.

Role of Donor-Specific Regulatory T Cells in Long-Term Acceptance of Rat Hind Limb Allograft

BackgroundVascularized bone marrow transplantation (VBMT) is widely accepted as an efficient means of establishing chimerism and inducing tolerance. However, the mechanism underlying is poorly understood. Recently, regulatory T cells (Tregs) have been shown to play an important role in regulating immune responses to allogeneic antigens. In this study, we explored the role of Tregs in the induction of tolerance in an allogeneic hind limb transplantation model.Methodology/Principal FindingsForty-eight Lewis rats were divided into 6 groups. They received isografts and allografts from Brown-Norway hind limbs. Recipients in groups 1 and 2 received isografts and those in the other groups received allografts. The bone components of donor limbs were kept intact in groups 1, 3, and 5 but removed before transplantation into groups 2, 4, and 6. Tapered cyclosporin A (CsA) was administered to recipients in groups 5 and 6 after transplantation. During the 100-day observation period, all isografts survived, but the allografts in groups 3 and 4 were rejected within 8 to 12 days. CsA-treated intact allografts survived rejection-free for more than 100 days, and CsA-treated allografts lacking bone elements were rejected within 2 months. Stable peripheral chimerism and myeloid chimerism were observed in group 5. Declining peripheral chimerism and a lack of myeloid chimerism were observed in group 6. Donor-specific Tregs were exclusively detected in both peripheral blood and in the spleens of long-term recipient rats in group 5, with an increased FoxP3 mRNA expression in the allografts. This was further demonstrated to be responsible for donor-specific hyporeactivity by in vitro one-way mixed lymphocyte reaction (MLR).Conclusion/SignificanceBone components in the allogeneic hind limbs can induce myeloid chimerism and donor-specific Tregs may be essential to tolerance induction. The bone-removal hind limb model may be a suitable counterpart to the induction of tolerance in the study of limb transplantation.

A Modified Rat Model of Acute Limb Allograft Rejection

Background The purpose of this study was to determine the feasibility of a simplified model of acute limb allograft rejection. Methods Wistar rats were donors (n = 18), and Sprague-Dawley (SD) rats were recipients (n = 36). They were divided into a traditional and a modified model group. In the traditional group, the hind limb of the recipient was removed; blood vessels, bone, and nerve anastomoses were performed. In the modified group, the hind limb of the recipient was maintained while the allografted limb was transplanted near inside the original hind limb with only blood vessel anastomoses performed, and the donor limb was fixed in place by suturing muscle and skin. Results The ischemic time of the donor limbs in the modified group was significantly less than the traditional group (67 ± 19.1 minutes vs 127 ± 15 minutes; P < .0001). In the traditional group, 12 models (66.7%) were successful and 6 failed, whereas in the modified group, 17 (94.4%) were successful and 1 failed ( P = .087). Acute rejection occurred in all surviving rats; the time and characteristics of rejection were similar in the 2 groups. Conclusions The simplified rat hind limb allotransplantation model described herein offers a greater success rate and shorter operative time than the traditional model while providing the same rejection characteristics.

Long‐term functional donor site morbidity after ulnar forearm flap harvest

The purpose of this study was to evaluate long-term functional donor site morbidity following ulnar forearm flap harvest taking both subjective and objective criteria into consideration. In this retrospective analysis, 61 patients were evaluated for subjective and objective donor site morbidity 3 to 164 months after flap harvest, and the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire was used for evaluation of subjective hand function. There was no significant grip strength decrease in the donor limbs. Two patients developed severe functional impairment of the donor forearm. DASH scores displayed only minor functional impairment, with marginally improving scores with increasing time lag to surgery. Low donor site morbidity was found after ulnar flap harvest. However, minor rates of patients suffered from severe impairment of the hand function. Therefore, we recommend using the nondominant limb and informing the patients in detail about the specific functional limitations.

Homeochronous Usage of Structural Bone Allografts with Vascularized Fibular Autografts for Biological Repair of Massive Bone Defects in the Lower Extremities after Bone Tumor Excision

We report the clinical outcomes of homeochronous usage of massive bone allografts with vascularized fibular autografts for the biological repair of lower-extremity bone defects secondary to bone tumor excision. Large bone defects in the lower extremities of 17 patients (10 men and seven women; age range, 6 to 34 years) who underwent bone tumor excision were repaired using massive bone allografts along with vascularized fibular autografts. After 6 to 48 months (mean, 20.2 months) of follow-up, the wounds at the donor and recipient sites healed in one stage, the monitoring flaps remained viable, the immune response to the massive bone allografts was minimal, and there were no complications in the donor limbs. Of the 17 patients, 13 and 3 cases showed radiographic union in 6 months and 8 months after surgery, respectively; one case of malignant synovioma showed recurrence, and therefore, leg amputation was performed 2.5 months after surgery. None of the massive bone allografts were absorbed or fractured at the last follow-up. The Mankin evaluation rating was excellent in eight cases, good in five cases, fair in two cases, and poor in two cases; the total rate of excellent and good cases was 76.47%. Homeochronous usage of massive bone allografts with vascularized fibular autografts is a satisfactory method for the biological repair of massive bone defects in the lower limbs after bone tumor excision.

Comparison of compression stocking with elastic bandage in reducing postoperative edema in coronary artery bypass graft patient

The removal of the saphenous veins in coronary artery bypass graft (CABG) surgery may cause leg edema. Compression therapy is often used to prevent postoperative edema. The objective of this study was to compare the efficacy of medical compression stocking (TED) and elastic bandage-type on donor limbs after CABG. The peripheries of lower limbs were measured at four regions (A: end of tarsal bones, H: heel , B: immediately above the ankle, C: largest circumference of the calf) at admission in 295 patients how CABG candidates and differences in these measurement points at discharge compared to measurements at admission time were calculated. The difference was considered as a measure of the effectiveness of two types of compression to prevent postoperative edema in donor limbs after CABG. The alterations of 396 donor limbs of 295 patients were examined after CABG at admission and discharge time. In 101 patients veins for graft were taken from both lower limbs. After analysis, if subjects had worn TED stockings, the peripheries of donor limbs at discharge were less than at admission time in the A and H regions compared to elastic bandage group (P(A) = 0/009), (P(H) = 0/012). The conclusion reached was that using the kind of knee length compression stocking (TED stocking , Kendall Co.) is more effective edema at foot and heel regions in donor limbs after CABG than elastic bandages.

Structural bone allografts with intramedullary vascularized fibular autografts for the treatment of massive bone defects in extremities

Objective To report the clinical outcome of repairing massive bone defects biologically in limbs by homeochronous using structural bone allografts with intramedullary vascularized fibular auto-grafts. Methods From January 2001 to December 2005, large bone defects in 19 patients (11 men and 8 women, aged 6 to 35 years) were repaired by structural bone allografts with intramedullary vascularized fibular autografts in the homeochronous period. The range of the length of bone defects was 11 to 25 cm (mean 17.6 cm), length of vascularized free fibular was 15 to 29 cm (mean 19.2 cm), length of massive bone allografts was 11 to 24 cm (mean 17.1 cm). Location of massive bone defects was in humerus ( n = 1), in femur ( n = 9) and in tibia ( n = 9), respectively. Results After 9 to 69 months (mean 38.2 months) follow-up, wounds of donor and recipient sites were healed in I stage, monitoring-flaps were alive, eject reaction of massive bone allografts were slight, no complications in donor limbs. Fifteen patients had the evidence of radiographic union 3 to 6 months after surgery, 3 cases united 8 months later, and the remained one case of malignant synovioma in distal femur recurred and amputated the leg 2.5 months, post-operatively. Five patients had been removed internal fixation, complete bone unions were found one year postoperatively. None of massive bone allografts were absorbed or collapsed at last follow-up. Conclusion The homeochronous usage of structural bone allograft with an intramedullary vascularized fibular autograft can biologically obtain a structure with the immediate mechanical strength of the allograft, a potential result of revascularization through the vascularized fibula, and accelerate bone union not only between fibular autograft and the host but also between massive bone allograft and the host.

Onset of ETS expression is not accelerated by premature exposure to signals from limb mesenchyme

The ETS transcription factors ER81 and PEA3 are expressed in discrete populations of sensory and motor neurons and regulate late events in neuronal development and limb innervation. Although initiation of ETS expression requires limb-derived signals, we show here that precocious axon growth into transplanted older donor limbs, which prematurely exposes neurons to limb-derived signals, does not accelerate the onset of expression of Er81 or Pea3. Similarly, neither MN-cadherin, which is reportedly regulated by ER81, nor T-cadherin is expressed precociously in neurons innervating older donor limbs. Thus, neurons must attain a particular level of differentiation to respond to inducing signals from limb. We also show that signals emanating from limb mesenchyme are sufficient to initiate Er81 and Pea3 expression in sensory and motor neurons in the absence of myogenic cells in Sp(d) mutant mice and that induction of ETS expression is unlikely to directly involve retinoid signaling from limb mesenchyme.