Radial Graft Research Articles

The radial artery in coronary surgery, 2018.

It is now 25years since the radial artery (RA) was reintroduced in coronary surgery. It has evolved into being a significant coronary artery bypass conduit and ranks third in usage after the internal thoracic artery (ITA) and saphenous vein grafts (SVG). Its advantages are that it can be readily and efficiently harvested, is of good length and appropriate size for coronary artery bypass graft (CABG) surgery, is robust and easy to handle, and remains free of atheroma, and there is minimal wound morbidity. The RA must be used judiciously with attention to spasm prophylaxis because of its muscular wall, and by avoiding competitive flow. Its patency is equivalent to the ITAs when placed to similar coronary territories and under similar conditions (stenosis, size, quality) and RA patencies are always superior to those of SVG in both observational and randomized studies-88-90% versus 50-60% at 10years, and 80-87% versus 25-40% at 20years. Its use and excellent patencies result in survival results equivalent to bilateral internal thoracic artery (BITA) grafting and always superior to left internal thoracic artery (LITA) +SVG. Typical radial artery multiarterial bypass grafting (RA-MABG) 10-year survivals are 80-90% versus 70-80% for LITA-SVG. In general, for every 100 patients undergoing CABG, 10 more patients will be alive at 10years post-operatively. The RA also is important in achieving total arterial revascularization, and several reports indicate a further survival advantage for patients having three arterial grafts over two. The RAs are especially useful in diabetic, morbidly obese patients, those with conduit shortage, and leg pathology, and in coronary reoperations. Although the RA has equivalent patencies to the right internal thoracic artery (RITA), it is much more versatile. RAs that have been instrumented by angiography or percutaneous coronary intervention should be avoided. The radial artery has proved to be an excellent arterial conduit, is equivalent to but more versatile than the RITA, and is always superior to SVG. Its use should be part of every coronary surgeon's skill set.

Asymmetrical endothelial cell migration from invitro Quarter-Descemet membrane endothelial keratoplasty grafts.

PurposeTo investigate in vitro central and peripheral corneal endothelial cell (EC) migration from Quarter–Descemet membrane endothelial keratoplasty (Quarter‐DMEK) grafts.MethodsQuarter‐DMEK grafts were obtained from 10 corneas ineligible for transplantation but with intact and viable ECs. Ten Quarter‐DMEK grafts were ‘sandwiched’ between two glass slides and cultured over 1 week in a humidified atmosphere at 37 °C and 5% CO2. Cell migration was evaluated by light microscopy at standardized time intervals. In addition, immunohistochemistry analyses were performed to assess the detailed structural organization of ECs in the corneal centre and far periphery.ResultsEndothelial cell (EC) migration occurred from the radial cut graft edges, but not from the far peripheral area. Cell migration followed three different migration patterns: (1) individual cell migration, (2) uncoordinated cell migration of cell clusters and (3) collective migration in which ECs moved as a sheet. Immunostaining showed the presence of ECs up to the far periphery but with different expression patterns of phenotypical markers ZO‐1, Na+/K+ ‐ATPase and vimentin compared to central ECs.Conclusion In vitro EC migration from Quarter‐DMEK grafts occurs along the radial cut edges with a decrease in migration activity towards the corneal far periphery. No migration occurred along the outer peripheral corneal edge possibly due to a different anatomical matrix in the far periphery. Hence, ECs from the far periphery may not contribute to corneal clearance of the adjacent bare area after Quarter‐DMEK surgery, but these cells may constitute a valuable cellular reserve on the graft.

Comparison of Distal Transradial in the Anatomical Snuffbox versus Conventional Transradial Access for Coronary Angiography and Intervention-An Experience in 100 cases

Background: Distal transradial access in the anatomical snuffbox has advantages over standard proximal access in terms of patient and operator comfort levels and risk of ischemia. Radial artery preservation could be a relevant issue in patients requiring multiple radial artery procedures and coronary bypass with the use of a radial graft or construction of Arterio-Venous fistula in patient of chronic kidney disease. One relevant drawback is the challenging puncture of a small and weak artery, with a steeper learning curve.Objectives:This study sought to compare the feasibility, safety and complications of coronary angiogram and intervention betweenthe distal transradial in the anatomical snuffbox and conventional transradial access.Methods: In this cross sectional studya total of 100 patients were assigned to perform coronary angiogram or intervention through conventional transradial accessand distal transradial in the anatomical snuffboxfrom November 2017 to April 2018 in theDepartment of Cardiology, Bangabandhu Sheikh Mujib Medical University (BSMMU). We divided the total patient in two groups, with 50 patientsin each group. All of them had normal pulse in theirradial and dorsal radial artery.One group was subjected toconventional right transradial accessand another to rightdistal transradial in the anatomical snuffbox.Demographic features &complications were recorded.Results: The overall procedural success was 98% which was greater than expected in our early clinical experience for distal transradial access with 48 successful accesses out of 50 patients and for conventional radial approach it was also 98%.There was failure to access of distal radial artery in two casesthat may be due to hypoplastic/vasospastic distal radial artery and for conventional radial artery radial artery spasm was the cause. Patients of conventional radial access had more spasm, hematoma, numbness and hospital stay (p< 0.001) than distal radial access. Considering all, it may be said thatdistal transradialaccess was very much effective and safe as there was less spasm, more comfortable to the patient, no hand ischemia, hematoma, numbness, and early hospital discharge.Conclusion: Distal transradial access in the anatomical snuffbox for coronary angiogram and intervention is abetter alternative, safe and feasible option to conventional transradial access for both patients and operators.University Heart Journal Vol. 13, No. 2, July 2017; 40-45

Outcomes of Radial Nerve Grafting In Children After Distal Humerus Fracture.

To report the results of radial nerve grafting in 7 children who sustained a radial nerve injury following a distal humeral fracture. Seven children, mean age 6 years (range, 4-11 years), underwent nerve grafting for radial nerve injuries following distal humeral fractures. The mean interval between injury andsurgery was 6.7 months (range, 6-9 months). In all cases, 3 sural nerve graft cables were used, of mean length 8.6 cm (range, 6-12 cm). Mean follow-up was 19.9 months (range, 12-24 months). Wrist, finger, and thumb extension range of motion and strength were evaluated at final follow-up, using the British Medical Research Council (BMRC) rating scale. The radial nerve was entrapped within the fracture site in 2 patients, and in 5, it was completely interrupted without entrapment. All patients obtained full active wrist extension with grade M4 BMRC strength. For finger extension, all patients were graded as M4, obtaining fullmetacarpophalangeal finger and thumb extension, with the wrist in neutral in 3 patients andfully extended in 4. During the thumbs-up test, 4 patients achieved complete extension of allthumb joints, and 3 exhibited metacarpophalangeal extension lag, averaging 30°. Nerve grafting of radial nerve injuries at the level of the distal humerus in children can yield excellent outcomes. Therapeutic V.

Descemet Membrane Endothelial Keratoplasty with Irregular-Edged Graft: A Salvage Method for Large Radial Graft Tears.

Large radial tears of donor Descemet membrane (DM) during the preparation of Descemet membrane endothelial keratoplasty (DMEK) grafts can make the trephination stage impossible because of small graft diameter. This results in irregular-edged grafts. In this study, we report two pseudophakic bullous keratopathy patients who underwent DMEK surgery with irregular-edged Descemet membrane (DM) grafts. Main outcome measures were preoperative and postoperative 1-, 3-, and 6-month best corrected visual acuity (BCVA), endothelial cell density (ECD) and central corneal thickness (CCT). Intraoperative and early postoperative complications were also evaluated. Both irregular-edged grafts were successfully implanted into the anterior chamber, unfolded, and attached to the posterior corneal stroma. Patients’ BCVA at 6 months was 1.0 (Snellen equivalent: 20/20) and 0.6 (Snellen equivalent: 20/32) respectively. Decrease in ECD at the last visit was 27% and 25%. CCT decreased from 723 μm and 850 μm to 530 μm and 523 μm, respectively. No intraoperative complications occurred except for the large radial Descemet membrane graft tears that developed during donor DM stripping. None of the cases needed a rebubbling procedure postoperatively. We have demonstrated that irregular-edged DM grafts can be successfully implanted for DMEK surgery with good clinical outcomes.

Invited Commentary

Invited Commentary

Effectiveness of radial artery–based multiarterial coronary artery bypass grafting: Role of body habitus

BackgroundThe multiarterial grafting survival advantage noted in the overall population undergoing coronary artery bypass grafting is not well defined in the obese. We investigated the early to late survival effects of the radial artery in left internal thoracic artery–based multiarterial bypass grafting (radial artery-multiarterial bypass grafting) versus single arterial bypass grafting (left internal thoracic artery-single arterial bypass grafting) in obese patients. MethodsWe analyzed 15-year Kaplan–Meier survival in 6102 patients receiving primary, left internal thoracic artery–based coronary artery bypass grafting with 2 or more grafts divided into body mass index groups: nonobese (<30 kg/m2) and all-obese, comprised of mildly obese (30-35 kg/m2) and morbidly obese (>35 kg/m2). Risk-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) of radial artery-multiarterial bypass grafting versus left internal thoracic artery-single arterial bypass grafting were derived via Cox regression and applied separately for early (<0.5 years), intermediate (0.5-5 years), and late (5-15 years) follow-up in each body mass index cohort. Propensity score matching between radial artery-multiarterial bypass grafting and left internal thoracic artery-single arterial bypass grafting cohorts within the body mass index groups was performed as a corroborating analysis. ResultsRadial artery-multiarterial bypass grafting was more frequently used in obese patients who were younger (62 ± 10 years; mild/morbid: 45.4%/54.4% radial artery-multiarterial bypass grafting) compared with nonobese patients (66 ± 10 years; 37.4% radial artery-multiarterial bypass grafting). Unadjusted 15-year survival was significantly better for radial artery-multiarterial bypass grafting in all body mass index groups. Multivariate analysis showed a survival benefit of radial artery-multiarterial bypass grafting over the entire 0- to 15-year study period in the all-obese cohort (HR, 0.85; 95% CI, 0.74-0.98) and was more pronounced in the mildly obese (HR, 0.79; 95% CI, 0.66-0.96) versus morbidly obese (HR, 0.88; 95% CI, 0.69-1.13). The radial artery-multiarterial bypass grafting survival benefit was realized between 0.5 and 5 years postoperatively and was comparable for all-obese (HR, 0.69; 95% CI, 0.51-0.94) and nonobese (HR, 0.68; 95% CI, 0.52-0.88) groups. Propensity score matching was confirmatory. ConclusionsRadial artery-multiarterial bypass grafting confers a long-term survival advantage in both obese and nonobese patients.

Synthesis of novel GA-g-PAM/SiO2 nanocomposite for the recovery of rare earth elements (REE) ions from aqueous solution

The study highlights the preparation of novel Gum Arabic (GA) grafted polyacrylamide based silica nanocomposite using in-situ radial graft copolymerization method. The presence of radicals involved in synthesis of GA-g-PAM was detected using DMPO as a spin trapping agent by Electron paramagnetic resonance (EPR) analysis and the possible reaction pathway was proposed. The novel GA-g-PAM/SiO2 nanocomposite was characterized by Elemental analyzer (CHNS/O), Fourier transform infrared spectroscopy (FTIR), X-ray diffraction (XRD), Transmission electron microscopy (TEM), Atomic force microscopy (AFM), Brunauer Emmett and Teller (BET) and zeta potential (ZP) to study the chemical, structural and textural properties of nanocomposite. The successful incorporation of silica in grafted copolymer matrix was confirmed by FTIR and XRD analysis. The results indicated that surface area increased significantly after formation of GA-g-PAM/SiO2 compared to parental polymer (GA) matrix and 273.55 m2/g surface area was determined for GA-g-PAM/SiO2 nanocomposite. The recovery of rare earth elements (REE) from aqueous solution was also investigated using GA-g-PAM/SiO2 nanocomposite. The optimum conditions for REEs adsorption were determined from the batch adsorption experiments. The adsorption kinetics for REEs were well described by pseudo first order model. The adsorption equilibrium data fitted well with Langmuir isotherm except for Sc ions. The thermodynamic studies confirm that the adsorption is spontaneous and endothermic. Desorption studies affirmed the regenerative efficiency of loaded REEs up to three cycles.

Transulnar cardiac catheterization and percutaneous coronary intervention: techniques, transradial comparisons, anatomical considerations, and comprehensive literature review.

Ulnar arterial access for cardiac catheterization and intervention is an alternative approach compared with radial or femoral access. Ulnar access is infrequently performed since the radial artery is readily palpable and is commonly used worldwide to minimize vascular complications from femoral access. Nevertheless, ulnar access provides a suitable access site in patients who are poor candidates for femoral access, have pre-existing radial occlusion, radial artery hypoplasia or hyperplasia from prior radial artery procedures, radial stenosis, radial loops, radial tortuosity, small radial arteries, and/or have future need for radial graft for dialysis or coronary artery bypass graft. Furthermore, femoral access is the standard default option if radial access fails. Consequently, learning ulnar access provides a suitable forearm alternative to avoid femoral access when deemed high risk or undesirable. This review discusses the techniques of ulnar access, advantages and disadvantages of ulnar versus radial access, the clinical trials on ulnar cardiac catheterization and its associated complications.

The radial approach to the wrist with styloidectomy: A cadaver study

The radial approach to the wrist is already used in several surgical techniques such as radial styloidectomy and Zaidemberg's vascularized radial graft. The aim of our work was to describe the surgical anatomy of that approach and to determine the acceptable limits of radial oblique styloidectomy that does not damage the anterior and posterior radiocarpal ligaments. This radial approach was performed on 11 cadaver specimens. The superficial branches of the radial nerve and the antebrachial cephalic vein were carefully located in the superficial plane. The radiocarpal articular capsule was opened longitudinally between the first and second compartments of the extensor tendons. We drew the oblique radial styloidectomy line at 3, 6 and 9mm from the apex of radial styloid process on the articular surface and then measured the width of ligaments theoretically taken away by the styloidectomy. An oblique radial styloidectomy of less than 6mm preserved the anterior and posterior radiocarpal ligaments. There was one case of radial artery damage while opening the joint capsule. The radial approach to the wrist as described in this work provided good access to the radial styloid process, the radioscaphoid joint and the proximal pole of the scaphoid, if the approach is done carefully to preserve the superficial branches of the radial nerve, the antebrachial cephalic vein and the radial artery. Radial styloidectomy can be performed up to 6mm from the apex without significantly damaging the radiocarpal ligaments, particularly the volar ones.

Association between CK-MB Area Under the Curve and Tranexamic Acid Utilization in Patients Undergoing Coronary Artery Bypass Surgery.

Myonecrosis after coronary artery bypass graft (CABG) surgery is associated with excess mortality. Tranexamic acid (TA), an anti-fibrinolytic agent, has been shown to reduce peri-operative blood loss without increasing the risk of myocardial infarction (MI); however, no large study has examined the association between TA treatment and post-CABG myonecrosis. In the MC-1 to Eliminate Necrosis and Damage in Coronary Artery Bypass Graft Surgery II trial, inverse probability weighting of the propensity to receive TA was used to test for differences among the 656 patients receiving and 770 patients not receiving TA. The primary outcome was creatine kinase MB (CK-MB) area under the curve (AUC) through 24h. The secondary outcome was 30-day cardiovascular death or MI. Patients who received TA were more frequently female, had a previous MI, heart failure, low molecular weight heparin therapy, on-pump CABG, valvular surgery, and saphenous vein or radial grafts. The median 24-h CK-MB AUC was higher in TA-treated patients [301.9 (IQR 196.7-495.6) vs 253.5 (153.4-432.5) ng h/mL, p < 0.001]. No differences in the 30-day incidence of cardiovascular death or MI were observed (8.7 vs 8.3%, adjusted OR 0.99; 95% CI 0.67-1.45, p = 0.948). In patients undergoing CABG, TA use was associated with a higher risk of myonecrosis; however, no differences were observed in death or MI. Future larger studies should be directed at examining the pathophysiology of TA myonecrosis, and its association with subsequent clinical outcomes.

Incidences of Coronary Artery Bypass Graft Failures at Waitemata District Health Board–A 3.5 Year Analysis

Background: After coronary artery bypass graft (CABG) surgery, left internal mammary artery (LIMA) grafts have superior patency rates compared to saphenous-venous-grafts (SVG) that degenerate with time. We sought to assess graft failure in patients with prior CABG in our DHB. Methods: Patients who underwent CABG (± valve surgery) between October 2012 and March 2016 who re-presented for clinically-indicated repeat coronary angiography were included. Baseline demographics, clinical characteristics, grafts used and re-presentation reasons were analysed. A graft was deemed to have failed if it had ≥75% stenosis (very early in ≤3months, early ≤12months). Results: 28 consecutive patients were identified: 86% males (mean: age at surgery 67, BMI 28 kg/m2, eGFR 64 mL/min), 36% diabetics, 71% hypertensives, 75% dyslipidaemics and 11% current smokers. All had a LIMA graft, 89% (n = 25) SVG's and 11% (n = 3) had radial grafts. Mean time to re-presentation was 209 days (46% angina, 29% acute coronary syndrome, 14% VF arrest, 11% cardiac failure). 39% (n = 11) had graft failure [9 VG; 2 LIMA], the majority [91% (n = 10)] in ≤12 months; 55% (n = 6) in ≤3months (4 VG; 2 LIMA grafts). Males (p = 0.009) and hypertensive patients (p = 0.037) were more likely to re-present. Being male trended with ≤3months-graft-failure [p = 0.061]. No other clinical predictors for graft failure were observed. Conclusion: Our small study had a high incidence of early graft failure, possibly commoner in males (p = NS). A larger cohort may identify definite clinical predictors for failure.

Coronoid reconstruction with an osteochondral radial head graft

Chronic coronoid deficiency can occur subsequent to coronoid fracture malunion/nonunion or to coronoid hypoplasia or dysplasia resulting from injury during development. Several surgical options have been described to treat this difficult condition, but results are equivocal. We hypothesized that a modified coronoid reconstruction using a radial head osteochondral graft could restore elbow stability and congruity and that a technique involving rigid internal fixation would promote graft union. The coronoid was reconstructed using an osteochondral fragment from a frozen allograft radial head in 3 young women affected by complex post-traumatic elbow instability and incongruity resulting from coronoid deficiency. To promote bone healing, the fragment was kept as large as could be fitted in place, the cut surface compressed onto the remaining coronoid was as large as possible, the medial portion of the radial head (containing dense bone) was used, and 3 lag screws were inserted in different directions. At a mean follow-up of 26 months, all 3 patients achieved a painless, congruent stable joint with a functional range of motion. Computed tomography scans performed 3 months after surgery showed complete union of the graft in all the patients. Each patient rated herself as "almost normal" or "greatly improved" on the Summary Outcome Determination scale. Coronoid reconstruction with a radial head osteochondral allograft was successful in restoring stability and function in chronically unstable elbows with coronoid deficiency. Strong fixation using a large segment of the medial radial head achieved rapid graft healing.

Graft failure prior to discharge after coronary artery bypass surgery: a prospective single-centre study using dual 64-slice computed tomography.

The purpose of this study was to assess the incidence and predictors of graft failure prior to discharge. Multi-slice computed tomography has the ability to evaluate graft patency in a non-invasive way. Of 145 consecutive patients who were screened, 73 were included in the study (78% male, mean age 65 years). A total of 206 grafts were analysed (2.8±0.9 grafts/patient). Of the 206 grafts, 126 were venous, 72 were left internal mammary, five were right internal mammary and three were radial grafts. We evaluated 100% of proximal anastomoses sites and 92% (190/206) of the distal anastomoses. We identified five patients (6.8%) who had at least one occluded graft. A total of seven out of 206 (3.4%) grafts were occluded. Independent predictors of successful graft outcome were left anterior descending artery as a recipient artery, good distal run-off as assessed by a surgeon and vessel size larger than 2 mm. The results demonstrate that the in-hospital acute graft failure rate is 3.4% (6.8% of patients). Multi-slice computed tomography is a robust technique to assess novel therapies to reduce the rate of graft attrition further, and might be clinically useful in patients with persistent or early recurrence of symptoms after CABG.

Long-term Radial and Internal Mammary Coronary Graft Patency is Superior to Venous Grafts

Long-term Radial and Internal Mammary Coronary Graft Patency is Superior to Venous Grafts

Free radial artery as an alternate conduit in CABG

Objective: This study was under taken to explore the potential of the Free Radial Graft as a safe efficient and suitable alternative conduit in coronary artery bypass grafting incase of in availability of the more established conduits like the IMA and Great Saphenous Vein graft especially in redo surgery. Method: This prospective randomized single center trial was conducted on three groups of patients under going CABG. The study was conducted from 1st January 1999 to December 2002.The first group A (n=15 with mean age of 47.05±8.35years) Radial artery was used for grafting in Right and Left sided grafts except the LAD. In the second group B (n=15 with a mean age of 54.80±11.14 years) Great Saphenous Vein was used for grafting in Right and Left sided grafts except the LAD. In the third group C (n=20 with a mean age of 55.93± 11.14 years) IMA was only grafted to LAD. Proximal ends of both the GSV and the Radial Artery were anastomosed to the Aorta. All patients were male . Follow up was done in these patien ts both by non invasive and invasive methods such as ETT , Thallium scan , Angiography. Comparison was mainly done between the Radial artery and the Great Saphenous Vein taking as granted that the IMA g the best graft for the LAD in all cases. Results: IMA was always applied to LAD in all patients in the three groups. In group (A) Radial Artery was grafted to RCA in 5 (33.3%) pts. Diagonal in 4 (26.7%)pts. Obtuse Marginal 12(80%) pts. And PDA 3 (20%) pts. In group (B) Great Saphenous Vein was grafted to RCA in 6(40%)pts. Circumflex 1(6.7%)pts. Diagonals 2 (13.3%) pts. Obtuse marginals 6 (40%) pts. And on PDA 4(20%) pts. All patients were regularly followed up for 18 months to 24 months. Post operative angina was reported in 2 (13.3%)pts. in group A and 5(33.3%) pts. In group B (p=0549). ETT was done in all these pts. Was positive in 1(6.7%) in group A and 2 (13.3%) in group B (p=0.309). Thallium scan was done in all the study population and was found positive in 4 (26.7%) in group A and 5 (33.3%) in group B Patients(p=0.265). Coronary angiograms were done on 10 patients out of each group. In group A the grafts were patent in 9 patients (90%). In the group B the grafts were found patent in 8 (86%) patients.(p=0.543). Moderate Graft stenosis was found in 01 patient in group B and none in group A (p=0.35). Totally blocked grafts were found in 01 patients in each group (p=1.00).

Optical Coherence Tomographic Visualisation of 10-Years-old Radial to Right Coronary Artery Anastomotic Site during Percutaneous Coronary Intervention to Occluded Radial Graft

Optical Coherence Tomographic Visualisation of 10-Years-old Radial to Right Coronary Artery Anastomotic Site during Percutaneous Coronary Intervention to Occluded Radial Graft

Anterior Spinal Reconstruction to the Clivus Using an Expandable Cage After C2 Chordoma Resection Via a Labiomandibular Glossotomy Approach: A Technical Report

En bloc resection of high-cervical chordomas is a technically challenging procedure associated with significant morbidity. Two key components of this procedure include the approach and the method of spinal reconstruction. A limited number of reported cases of en bloc resection of high-cervical chordomas have been reported in the literature. We report a novel case using an expandable cage to reconstruct the anterior spinal column above C2 with fixation to the clivus. We also report a novel anterior approach to the high-cervical spine via a midline labiomandibular glossotomy. We detail the management of complications related to 2 instances of wound dehiscence and hardware exposure requiring two additional operations. The final surgical procedure involved explantation of the anterior cervical plate and use of a vascularized radial graft to close the posterior pharyngeal defect and protect the hardware. At 26-month follow-up, the patient remained disease free without any neurologic deficit. We report the novel use of the midline labiomandibular glossotomy for surgical approach and reconstruction of the anterior column to the clivus with an expandable cage. The unique features of this operative strategy allowed the surgical team to tailor the construct intraoperatively, resulting in solid arthrodesis without significant neurologic sequelae. Labiomandibular glossotomy for approach to high anterior cervical chordomas followed by craniospinal reconstruction to the clivus with an expandable cage represents a novel technique for managing high cervical chordomas.

Results of nerve grafting in radial nerve injuries occurring proximal to the humerus, including those within the posterior cord.

OBJECT Results of radial nerve grafting are largely unknown for lesions of the radial nerve that occur proximal to the humerus, including those within the posterior cord. METHODS The authors describe 13 patients with proximal radial nerve injuries who were surgically treated and then followed for at least 24 months. The patients' average age was 26 years and the average time between accident and surgery was 6 months. Sural nerve graft length averaged 12 cm. Recovery was scored according to the British Medical Research Council (BMRC) scale, which ranges from M0 to M5 (normal muscle strength). RESULTS After grafting, all 7 patients with an elbow extension palsy recovered elbow extension, scoring M4. Six of the 13 recovered M4 wrist extension, 6 had M3, and 1 had M2. Thumb and finger extension was scored M4 in 3 patients, M3 in 2, M2 in 2, and M0 in 6. CONCLUSIONS The authors consider levels of strength of M4 for elbow and wrist extension and M3 for thumb and finger extension to be good results. Based on these criteria, overall good results were obtained in only 5 of the 13 patients. In proximal radial nerve lesions, the authors now advocate combining nerve grafts with nerve or tendon transfers to reconstruct wrist, thumb, and finger extension.

A pathological fracture of the scaphoid revealing an intraosseous ganglion cyst

Intraosseous ganglion cyst is a benign bone lesion with histological similarities to the soft tissue ganglion cyst. Its location on the short bones, including the carpal bones has rarely been reported. The radiolucent carpal lesions are usually symptom-free found incidentally on radiographs of the wrist performed for other reasons. Detecting a pathological fracture of the scaphoid revealing an intraosseous ganglion cyst is exceptional. We report the case of a 21-year-old, right-handed male, presented with a one year history of progressive right-wrist pain, worsened since a month without a history of previous trauma. Plain radiographs and CT-scan revealed a cystic lesion of the scaphoid with a pathological fracture. He was successfully treated with curettage and packing with a Zaidemberg's vascularized radial graft without recurrence at two years postoperatively. Pan African Medical Journal 2016; 23