Secondary Contracture Research Articles

Prognostic efficiency of diagnostic blockade as a method of modeling the result of selective neurotomy of the motor branches of the median nerve in patients with cerebral palsy

BACKGROUND: A feature of the disease course in patients with spastic cerebral palsy is a combination of motor neurological disorders with contractures in extremity joints. Neurosurgical methods are currently the main treatment for correcting the pathological tone of the “spastic hand.” However, the decreased tone does not affect secondary (fixed) contractures; therefore, the effectiveness of this type of treatment is extremely dependent on the accurate selection of a certain category of patients. Presumably, diagnostic blockade of the median nerve can create a reversible model for planned neurosurgical treatment. The inclusion of this technique as a standard for examining a patient with spastic cerebral palsy before invasive tone-lowering treatment can radically promote treatment effectiveness. AIM: This study aimed to assess the prognostic effectiveness of diagnostic blockade as a method of modeling the result of selective neurotomy of the motor branches of the median nerve in patients with cerebral palsy. MATERIALS AND METHODS: A longitudinal prospective study enrolled 39 children (aged 5–18 years) with spastic cerebral palsy. Before neurosurgical treatment, each patient underwent a diagnostic n. medianus under electrical stimulation and ultrasound control. After a diagnostic blockade, only patients who had a good functional and goniometric response were selected for the study, which served as an indication for selective neurotomy of the median nerve, and orthopedic treatment was performed in children with a negative event. Patients referred for neurotomy underwent a standardized examination before treatment during the diagnostic blockade and after neurosurgical treatment. The examination included the assessment of the amplitude of passive and active movements in the joints of the upper extremities, muscle tone, and functional capabilities of the upper extremities and dynamometry. RESULTS: In comparison with the initial data, a significant increase in the amplitude of passive and active hand extension, passive and active abduction of the first finger, and upper limb functional capabilities according to the MACS classification and the Miller scale was determined both after the diagnostic blockade and after selective neurotomy of the motor branches of the median nerve. CONCLUSIONS: Based on the results of the study, the effect of the diagnostic blockade and neurosurgical treatment outcomes are unidirectional, which allows the use of blockade as a method for modeling the possible result in clinically complex cases of spastic hand. The use of diagnostic blockade in clinical practice makes it possible to adequately assess the severity of fixed contractures and reduce the pathological hypertonicity of the target muscles. Diagnostic blockade allows for the collection of sufficient information to make an objective decision about which type of treatment is most preferable for each patient – neurosurgical, orthopedic, or sequential use of both methods.

Clinical experience of using loop threads for tendon suturing of injured tendons of finger flexors in children's hands

BACKGROUND: Despite a significant progress in hand surgery, to date, the number of unsatisfactory functional outcomes in patients with injured flexor tendons of fingers still remains high, which underlines the importance and significance of the problem of flexor tendon repair in children. CLINICAL CASE DESCRIPTION: The authors present a series of clinical cases with the application of loop threads for suturing tendons in children with tendon injuries in deep finger flexors at different anatomical sites. They share their experience in using loop threads for tendon suturing in zones II, III, IV, V including tendon end reinsertion in zone I again with a loop thread. The primary task of surgical treatment of children with injured tendons of finger flexors is their restoration. In order to prevent secondary tendon ruptures, finger contractures, infectious complications and scarring of the tendon with surrounding tissues, it is recommended to use optimal suture material and surgical sutures that meets the basic requirements for tendon suturing . Specific pediatric anatomy must be taken into consideration as well. As the authors' clinical experience shows, a new approach to the restoration of injured finger flexor tendons with loop threads allows to avoid complications in 98% of cases. CONCLUSION: The implementation of loop tendon suturing into pediatric practice in combination with appropriate rehabilitation and motivation for the rehabilitation of a child and his/her parents opens up new prospects for the successful treatment of children with injured tendons of deep flexors of hand fingers.

EFFECTIVENESS OF PHYSICAL THERAPY AND REHABILITATION IN IMPROVING MOTOR SKILLS AND MENTAL FUNCTION IN CHILDREN WITH CEREBRAL PALSY

Cerebral palsy was first described by William John Little in 1846. There are many definitions of cerebral palsy that vary from author to author. However, we can say that cerebral palsy (CP) is a chronic non-progressive brain damage, postural and body motility disorder. Apart from sensorimotor abnormalities, some cases are accompanied by mental disorders as well as disorders of cognitive functions. It can occur during pregnancy, at birth or during the postnatal period, ie. prenatal, perinatal and postnatal - equally in both sexes. There are different classifications of cerebral palsy: according to changes in muscle tone, according to topographic features and according to the severity of the clinical picture.According to changes in muscle tone, they are divided into: Spastic form, Athetoid form, Ataxic form, Hypotonic form and Mixed form. According to the topography they are classified as: Diplegia, Quadriplegia, Hemiplegia, Triplegia and Monoplegia Physical therapy program is determined based on the clinical form of the disease. When determining a rehabilitation program, the principle of an individual approach is followed. Rehabilitation includes: physical medicine, kinesitherapy, reflex exercises according to Vojta, manual massage, thermotherapy, education of parents for rehabilitation at home; orthopedic aids; special education techniques. The aim of this study is to determine the role and impact of Physical Medicine and Rehabilitation in the treatment of children with Cerebral Palsy in early childhood. The research was conducted at the University of Southeast Europe - (Stul University) at the Faculty of Health Sciences in the Department of Physical Therapy and Rehabilitation, over a period of 6 months, from the beginning of April to the end of September 2023. 61 patients with cerebral palsy are included in the research, of which 28 are male, and the remaining 33 patients are female. The patients included in the research are classified into groups according to: gender, age and clinical form of cerebral palsy. The treatment of Cerebral Palsy (CP) has a complex character and includes medical, pedagogical and social rehabilitation. The individual tasks of the rehabilitation are determined after a functional examination of the motor abilities, where the main role is played by muscle tone, normal and pathological reflex motor activity, in the period up to 1 year of age. The goal of treatment with Physical Therapy and Rehabilitation is to achieve correct and timely development of movements and correction of pathological movement stereotypes (models), which occurred as a result of brain tissue damage. As for the motor deficit, kinesitherapy plays a major role. Established modern methods for kinesitherapy are the specialized methods for neuromuscular re-education of Vojta and Bobath. The Rood and Rabat methods werw also be used to facilitate the required movements and train coordination. Physical therapy and rehabilitation combined with kinesitherapy have an exceptional positive effect in: prevention of pathological primitive reflexes;creation and automation of normal active movements;saving irregular positions of the limbs and the whole body;establishment of balance and correct pattern of movement; fight against spasticity, secondary contractures and deformities; improvement of coordination and awareness of the body in relation to the environment.

PHYSICAL THERAPY AND NEUROREHABILITATION OF PATIENTS WITH CEREBROVASCULAR STROKE

Cerebral stroke represents an acute disturbance of circulation in the brain, which occurs with local and general brain symptoms. Main etiological factors are: arteriosclerosis, increased blood pressure, arterial hypotension, heart diseases, malformations of brain blood vessels, etc. Stroke is the most common neurological disease and the leading cause of mortality in the world, right after cardiovascular and malignant diseases. Cerebrovascular stroke is a focal neurological deficit caused by intracerebral hemorrhage. It is a condition that occurs due to a change in blood circulation in the brain and a very low supply of oxygen and nutrients to parts of the brain, which results in their damage and disruption of the functions that depend on them. There are two types of cerebrovascular stroke: ischemic - thrombosis and thromboembolism (85%) and hemorrhagic – intracerebral and subarachnoid bleeding (15%). The clinical picture can develop gradually or, the patient can suddenly fall into a coma. Absence of movements of the affected limbs predominates, always opposite to the side of the impact with an outburst of the facial nerve of the central type. Hemiplegia is a loss of the voluntary movements of one half of the body, caused by damage to the opposite brain hemisphere. The musculature is atonic, tendon reflexes are reduced or lost. The aim of the research is to determine the effectiveness of physical therapy and neurorehabilitation in patients with cerebrovascular brain stroke. Treatment of stroke: In the acute stage, physical therapy is aimed at preventing complications of the loco-motor apparatus (contractures, muscle and tendon retraction, heterotropic ossifications), the respiratory system (hypostatic pneumonia) and the skin (decubitus). This is achieved through treatment with position (frequent change of the position of the body in bed), passive exercises performed according to strictly defined rules, breathing exercises, exercises for healthy limbs and great care of the skin. The trophic changes of the skin are treated with ultraviolet radiation in suberythemic doses or with D’Arsonval currents. The research was conducted at the University of Southeast Europe - (Stul University) at the Faculty of Health Sciences in the Department of Physical Therapy and Rehabilitation, over a period of 6 months, from the beginning of From the beginning of May - to the end of October 2023. The research included 27 stroke patients, of which 11 patients had a left-sided stroke, and the remaining 14 patients had a right-sided stroke. According to the gender structure, 12 patients are male and the remaining 15 patients are female. After completing the six-month treatment with physical therapy, kinesitherapy and the methods of Vojta and Carl and Bertha Bobat, the results show great progress in almost all parameters. A decrease in tonic primitive reflexes, neck and labyrinthine tonic reflexes, reduction of extensor hypertonia, improvement of motor-reflex activity, proprioceptive afference, coordination, reduction of neck tone, foot reflex, stimulation of the grip reflex and improvement of the position of the neck, limbs and body. The presented results shows significant improvement in both groups of participants. Physical therapy and rehabilitation combined with kinesitherapy have an exceptional positive effect in: prevention of pathological primitive reflexes;creation and automation of normal active movements;saving irregular positions of the limbs and the whole body;establishment of balance and correct pattern of movement; fight against spasticity, secondary contractures and deformities; improvement of coordination and awareness of the body in relation to the environment.

The treatment of axillary hidradenitis suppurativa with a thoracodorsal artery perforator V-Y advancement flap: a case report

Hidradenitis suppurativa, a recurrent and chronic inflammatory skin disease, presents with extensive scars and multiple abscesses. Moreover, axillary hidradenitis suppurativa could be impacted by scar contracture, which can limit arm mobility. The most reliable treatment for advanced hidradenitis suppurativa is meticulous and radical excision. Several methods exist for the reconstruction of axillary wounds after reconstruction. Skin grafts are an option, but their drawbacks include secondary contracture and poor aesthetic results. Local flaps could be useful, but also have a limited arc of rotation for larger defects. Thoracodorsal artery perforator (TDAP) flaps have been proven to be very effective as part of the armamentarium for axillary wounds. Herein, we describe the use of a TDAP flap in a V-Y advancement fashion with minimal pedicle dissection. We only dissected the perforator pedicle about 1 to 2 cm from its muscle entry point. With this maneuver, the flap could be easily moved to cover the defect without vascular compromise. We found that the TDAP flap performed in a V-Y fashion, with a propeller design, was very useful for an axillary defect over an island. This procedure was simple, easy, and time-saving.

Prognostic efficiency of diagnostic blockade as a method of modeling the result of selective neurotomy of the motor branches of the musculocutaneous nerve in patients with cerebral palsy

BACKGROUND: A combination of movement disorders with contractures in the joints is a feature of upper limb lesions in patients with spastic forms of cerebral palsy. As part of the spastic hand syndrome, contractures are differentiated into primary and secondary. Primary contractures are caused by muscle spasticity, whereas secondary contractures are caused by the structural shortening of the muscle motor segment in relation to the bone, which can subsequently lead to deformities of articular surfaces. In theory, the use of diagnostic blockade as a mandatory procedure in patient examination before selective neurotomy of the peripheral nerves on the upper limb makes it possible to optimize the result of tone-lowering treatment because of the accurate selection and exact category of patients in whom neurosurgical treatment can be effective.
 AIM: To assess the prognostic effectiveness of diagnostic blockade for modeling the result of selective neurotomy of the motor branches of the musculocutaneous nerve in patients with cerebral palsy.
 MATERIALS AND METHODS: This longitudinal prospective study included an examination of 31 patients aged 517 years with spastic forms of cerebral palsy. Before neurosurgical treatment, each patient underwent a diagnostic blockade of the n. musculocutaneus under ultrasonography and neurostimulation. Before and after the diagnostic blockade and after the neurosurgical treatment, each patient was examined for the amplitude of passive and active joint movements, muscle tone, hand functionality, and dynamometry.
 RESULTS: Results of the data analysis showed a significant relationship between the state of the elbow joint during the simulation of surgical treatment and after neurosurgical treatment.
 CONCLUSIONS: The study showed the high prognostic effectiveness of diagnostic blockades when deciding on the techniques of treating tonic flexion contractures of the elbow joint as part of the spastic arm syndrome. The diagnostic blockade of the musculocutaneous nerve during the planning of surgical treatment makes it possible to create a reliable temporal model of selective neurotomy of the motor nerve branches.

Single Stage Excision and Thick Split Thickness Skin Graft Technique for Facial Giant Congenital Melanocytic Nevi with Consideration of Facial Aesthetic Subunits: A Case Report and Literature Review

Due to their three-dimensional anatomy, functional importance, and esthetic appeal, giant congenital melanocytic nevus (GCMN) of the face pose the greatest challenge to reconstructive surgeons, especially when there are few donors and a significant deformity. A 25-year-old male patient presented with a facial GCMN. GCMN management involves complete nevus removal and reconstruction using tissues of the same color, thickness, and as the surrounding skin. Some defect closure options were inapplicable due to the almost complete forehead defect. This study aims to report the author's successful experience treating an adult case of GCMN with single-stage excision and subunit facial restoration using thick split-thickness skin graft (STSG). In this case, thick STSG is considered to prevent the risk of secondary contracture and conspicuous discoloration. In addition to esthetic and functional outcomes, the patient's social status and self-esteem also improved. This technique promises esthetic results, such as reduced downtime, and improved psychological function.

Fournier’s gangrene reconstruction: A 10-year retrospective analysis of practice at Guys and St Thomas’s NHS Foundation Trust

Fournier's gangrene is a rare and potentially fatal condition that affects the external genitalia and perineum as a necrotizing soft-tissue infection. It is equally prevalent in men and women and although there are many ways to manage the condition, it must be done so effectively because there is a chance that life-threatening complications could develop. This retrospective study set out to fill any knowledge gaps, compare reconstructive options to those described in the literature, and promote reflection on current management. Between January 2010 and January 2020, all perineal debridement operation notes were examined. The primary conclusions were that a large majority of defects could be repaired using split skin grafts to reduce surgical time and donor site morbidity. To avoid secondary contracture and the need for revision surgery, full-thickness skin grafts should be used whenever possible to treat penile defects.

Quantification of elastic anisotropy of human skin in vivo with dynamic optical coherence elastography and polarization-sensitive OCT

The complex structure of skin ensures a broad range of biological functions. The loss of a large skin area due to trauma or disease usually requires reconstructive surgery that often involves grafting or flapping. The clinical need for non-contact objective measurements of skin elasticity is necessary to guide grafting procedures to minimize complications such as secondary contracture or hypertrophic scars. Here, we report a non-contact and non-invasive method combining acoustic micro-tapping optical coherence elastography (AμT-OCE) with polarization-sensitive (PS-) optical coherence tomography (OCT) to quantify anisotropic elastic properties of skin. We show that all three elastic constants that define skin’s anisotropic elastic deformation and the orientation of collagen fibers in the dermis can be determined from propagating elastic waves over the skin surface. Measurements were performed on healthy volunteers in vivo. A nearly incompressible transverse isotropic model of skin elasticity was used to reconstruct the moduli from experimental data after being validated in extensive numerical simulations. Finally, we demonstrate that combining several OCT modalities (structural OCT, OCT angiography, PS-OCT, and AμT-OCE) may provide rich information about skin and demonstrate the potential for complex characterization of scar.

Ankle contracture in people with acquired brain injury (ABI), intervention, and outcome following inpatient neurorehabilitation categorized by severity

Background: Acquired brain injury frequently causes difficulty with moving and walking, which if not actively managed, can lead to secondary contracture and deformity. Intervention to manage ankle contracture may include conservative methods (eg, serial casting, standing) or more invasive methods (eg, Achilles-tendon lengthening surgery). Methods: Data were extracted from the UK Rehabilitation Outcomes Collaborative database for all admissions from 2015 to 2018 with a diagnosis of acquired brain injury from 1 tertiary rehabilitation center. Clinical records were reviewed to identify the 101/357 (28%) with ankle contracture. Categorization according to the degree of contracture was performed, as mild (>plantigrade), moderate (<plantigrade to −20°), or severe (>−21°) based on ankle range of movement. Data were analyzed to determine the change in the range of movement, function, outcome, and categorize intervention type. Primary measures: range of movement, UK Functional Independence Measure+Functional Assessment Measure, and Functional Ambulatory Category. Results: In the cohort, significant improvement in range of movement occurred following treatment (54.17; P=0.000). Treatment interventions applied included stretch interventions such as serial casting. Standing programmes, orthotics, and task practice were the most frequently applied interventions. Achilles-tendon lengthening surgery was used in a small number of cases (n=13). A statistically significant change in the range of movement was not seen in the mild category (1.05; P=0.29) but was in the moderate (5.436; P=0.001) and severe categories (10.4; P=0.001). Improvement in locomotion was noted in all 3 groups (6.10; P=0.001) but was most pronounced in the moderate and severe groups. Discussion: Improved functional outcome was observed in mild contracture with less change in joint range. In those categorized as moderate and severe, greater improvement in joint range of movement as well as function were identified following intervention.

Unique indications for internal joint stabilizer for elbow instability.

Treatment of elbow instability remains challenging despite advancements in surgical techniques. The objective of this study was to evaluate obesity, advanced age or frailty, and altered cognitive function (because of mental handicap, stroke, dementia, or traumatic brain injury) as unique indications for the use of the internal joint stabilizer (IJS) to augment surgical treatment of elbow instability. This was a retrospective review of all patients 18 years and older with elbow instability who were managed with an IJS along with standard measures of care for their specific injury, such as fracture fixation and collateral ligament reconstruction. Patients were excluded if they did not have a minimum follow-up of 3 months. All patients were treated by a single shoulder and elbow fellowship-trained orthopedic traumatologist at an urban university-based level 1 trauma center. Twenty-two patients were included in the study. Five patients were 60 years of age or older. Nine patients had a body mass index of 30 or greater. Five patients had a history of 1 or more cerebral insults or cognitive impairment. The majority of patients (21/22; 95%) regained elbow stability after the index surgery. At last follow-up, 14 of 22 patients (63%) regained a functional arc of motion, defined as at least 100° arc of motion, and 77% of patients had at least 90° of motion. Complications requiring revision surgery included culture-negative recurrent elbow instability (n=1), deep infection (n=1), and IJS failure without recurrent instability (n=1). The IJS was removed in all 3 cases. Twelve patients underwent delayed IJS removal >2 months after the index surgery to grant additional time for bony and ligamentous healing and to permit secondary contracture release at the time of IJS removal. No complications were seen from delayed IJS removal. The IJS may be used to create elbow stability in complex patients, regardless of weight, frailty, cognitive function, neurologic insult, or other comorbidities. Unlike external fixation, the IJS does not require pin site care and is relatively light and low-profile. When augmenting surgical fixation for elbow instability, the IJS may be preferable for patients with complex comorbidities or social dynamics.

Reverse Neurocutaneous Flap Based on the Dorsal Branch of the Ulnar Artery for Palm Coverage in Children: Long-Term Results

Although the palm is spared mostly in severe burn injuries, it often is affected in children and requires radical excision of contracting scar tissue to allow normal hand development. Since alternatives are limited for palmar coverage, we primarily use a reverse-perfused, neurocutaneous dorsal ulnar artery flap. We report here our long-term follow-up results. We reviewed the long-term results of 10 postburn palmar contracture release and flap coverage procedures in 10 children. The applied flap was based distally on the dorsal branch of the ulnar artery and harvested along the ulnar aspect of the hand and wrist. The pivot point of the flap was located dorsally, close to the 4th and 5th metacarpal base. Patients were followed for a median period of 6 years (range, 4-20 years). Flap size ranged from 60-130 mm in length and 20-35 mm in width. This variation in flap dimensions resulted from different hand sizes, because of the various patient ages at surgery. All flaps survived, donor site healing was uneventful, and marginal flap necrosis occurred only once. Satisfactory restoration of range of motion without secondary contractures was observed. Moreover, we detected adequate progressive growth, adaptability and sensory recovery in all flaps. Over time, the flaps mostly become hairless and progressively flattened without debulking. The importance of this flap lies in the potential for considerable tissue mobilization to cover palmar defects without sacrificing any major vascular axis. The adequate progressive growth of the flap facilitates functional hand development in children. The predictable vascular anatomy, wide range, and durable, thin, and pliable skin make the reverse neurocutaneous dorsal ulnar artery flap an appealing option for soft tissue reconstruction of the palm in children. Therapeutic V.

Secondary healing property using Neoveil®, a polyglycolic acid bioabsorbable sheet on the oral mucosal defects

Neoveil® is a wound surface-covering agent composed of polyglycolic acid(PGA) effective for secondary healing. This study evaluated the secondary healing property of oral cavity mucosal defects using the PGA sheet. Thirty-four patients who underwent surgical excision of oral benign and malignant lesions, precancerous lesions, and tumors were evaluated. The PGA sheet was placed over the open wound to aid secondary healing. The defects were reviewed post-operatively for secondary healing, contracture, and secondary deformity. Male to female ratio was 20:14, and the mean age was 63.5 years. In all cases, the oral mucosal defect was present after the wide excision of the mucosal lesion. The PGA sheet was used as a surface covering agent which was found to be effective in secondary healing of the wound. Any side effects and adverse reactions which were caused by the PGA sheet was not evident. It can be used to avoid skin graft or free flap reconstruction or deformity from the direct closure in moderate size oral mucosal defect.

Choice of the method for eliminating postburn shoulder joint contractures

BACKGROUND: In the Russian Federation, over 400,000 patients with thermal injuries are registered yearly, with approximately 30% of them requiring hospitalization. Physicians pay special attention to the rehabilitation of patients with complications of deep burns. According to several authors, deep burns occur in 47% of cases. The most common complications of deep burns are contractures and limb deformities. Shoulder contractures occur in over 50% of patients. The outcomes and terms of a patients return to active social and working life depend on the timeliness and selection of an optimal surgical intervention from a wide range of reconstructive and plastic techniques.&#x0D; AIM: This study aimed to improve the functional and esthetic results of surgical treatment in patients with postburn shoulder joint contractures.&#x0D; MATERIALS AND METHODS: From 2011 to 2020, 198 patients underwent surgery, including 59% women and 41% men. Right shoulder, left shoulder, and right and left shoulder simultaneous joint contractures occurred in 54.5%, 38.5%, and 7% of cases, respectively. The patients age ranged from 18 to 72 years, and 99% of them were of working age. The scope of preoperative examination included clinical data, photographic documentation, duplex vascular scanning, and determination of the degree of contracture using a mechanical goniometer. Patients with grade I, II, and III shoulder joint lesions accounted for 29%, 60%, and 11% of the total number of cases, respectively. Early surgical rehabilitation prevents the development of secondary myogenic and arthrogenic contractures and accelerates the patients social reintegration. Local tissue plasty using the armpit adipodermal tongue-shaped flap, a nonperforated full-layer or split skin graft, a rotated flap based on perforating vessels, and the expander stretching method were used to eliminate contractures.&#x0D; RESULTS: Bacterial infection, total and marginal necrosis, hematomas, and seromas were not observed in the immediate postoperative period. Complete elimination of the shoulder joint contracture was achieved in 63% of cases, whereas joint mobility increased by over 60 in 30% of patients.&#x0D; CONCLUSIONS: The algorithm presented for choosing a method of surgical rehabilitation for patients with shoulder joint contractures leads to an increase in the efficiency of reconstructive surgery after burn injuries.

Transosseous Multiple Finger Flexor Tendon Pulley Reconstruction

Background: Closed finger flexor tendon pulley injuries occur most frequently in rock climbing but also during other heavy finger strength work or exercises. While single pulley injuries receive a conservative therapy, multiple pulley injuries often require a surgical repair, as otherwise they will lead to contracture and loss of range of motion and functionality. While established surgical techniques, which use bone encircling tendon graft techniques, were found to produce osteonecrosis of the phalanx, our new transosseous technique avoids this problem. Indications: All triple pulley injuries (A2,3,4) (grade-4b injuries) and double pulley injuries (A2,3 or A3,4) (grade-4a injuries) are indicated, if the injury is older than 10 days at the point of therapy start or the flexor tendons bowstringing is either not redressable in the ultrasound or extended. Also, grade-4a injuries are indicated, if a secondary contracture starts to build. Technique Description: Standard palmar-sided incision, followed by debridement of the tendon sheath, pulley flap, and, if applicable, scare tissue in between the flexor tendons and the bone is performed. Wire-guided 3.0-mm drill holes at the base phalanx at the level of the former distal portion of the A2 pulley are completed. Passing of the palmaris longus tendon through the drill hole and interlacing it as a “loop and a half” follows. Distal continuation through lacing the transplant through the remaining rims of the former pulleys and the flexor tendon sheath is then performed. Securing the repair after tendon gliding control to itself is completed. Postsurgically, the splint is immobilized for 2 weeks, followed by the use of a thermoplastic pulley support ring for 4 weeks with active mobilization. Results: No complications occurred during or after the surgery. In few cases, a restricted range of motion in the proximal interphalangeal (PIP) joint of the respective finger of up to 3 to 5 grade occurred. One patient, who had a presurgical PIP extension deficit of 30°, which was released during the surgery, developed over time again a 20° extension deficit. The functional outcome score ranged between good and excellent, with one case being only satisfactory. The sport-specific outcome score was either good or excellent for all patients, with one patient with contracture where it was satisfactory. No osteonecrosis of the phalanx was recorded. Discussion: For multiple pulley ruptures, various surgical techniques are described. We favored a modified “loop and a half” technique with a distal continuation to the A3 pulley. This combines the advantages of the “loop and a half” technique, as the strongest, and the Weilby repair, as the most functional repair. We recently noticed some cases with osseous necrosis of the phalanx following this repair, likely due to the high pressure of the circulation of the tendon graft onto the bone and its blood vessels. Therefore, we have modified our procedure into a transosseous repair, which is presented in this article. This approach was first evaluated in a cadaver study to exclude a potential risk of osseous failure (fracture) during stress caused by the drill hole. After ruling out this risk, the transosseous technique became our standard approach, as it combines the advantages of the “loop and a half” technique with those of the Weilby repair and decreases the pressure onto the dorsal cortex of the fingers base phalanx and thus the risk of osteonecrosis.

Number of synergies impacts sensitivity of gait to weakness and contracture

Muscle activity during gait can be described by a small set of synergies, weighted groups of muscles, that are theorized to reflect underlying neural control. For people with neurologic injuries, like cerebral palsy or stroke, even fewer synergies are required to explain muscle activity during gait. This reduction in synergies is thought to reflect altered control and is associated with impairment severity and treatment outcomes. Individuals with neurologic injuries also develop secondary musculoskeletal impairments, like weakness or contracture, that can impact gait. Yet, the combined impacts of altered control and musculoskeletal impairments on gait remains unclear. In this study, we use a two-dimensional musculoskeletal model constrained to synergy control to simulate unimpaired gait. We vary the number of synergies, while simulating muscle weakness and contracture to examine how altered control impacts sensitivity to musculoskeletal impairment while tracking unimpaired gait. Results demonstrate that reducing the number of synergies increases sensitivity to weakness and contracture for specific muscle groups. For example, simulations using five-synergy control tolerated 40% and 51% more knee extensor weakness than those using four- or three-synergy control, respectively. Furthermore, when constrained to four- or three-synergy control, the model was increasingly sensitive to contracture and weakness of proximal muscles, such as the hamstring and hip flexors. Contrastingly, neither the amount of generalized nor plantarflexor weakness tolerated was affected by the number of synergies. These findings highlight the interactions between altered control and musculoskeletal impairments, emphasizing the importance of measuring and incorporating both in future simulation and experimental studies.

Skin Grafting Using Collagen Fiber Orientation Matching.

Background:Skin contracture after skin grafting is undesirable. It is generally accepted that full-thickness skin grafts contract less than split-thickness skin grafts. However, unexpected secondary skin-graft contracture sometimes occurs after full-thickness skin grafting. We tried to elucidate the causes of skin contracture from the viewpoint of the orientation of collagen fibers to find a way to reduce skin-graft contracture.Method:First, we examined the collagen fiber orientation of the skin over the whole body in Sprague-Dawley rats. Next, two pieces of skin (width: 30 mm × 30 mm; thickness: ca. 2 mm) were stripped off a rat for grafting. The pieces were grafted to different sites so that the collagen fibers of the graft and surrounding skin ran parallel or perpendicular to each other. The collagen fiber orientation before and after the skin grafting was determined using Osaki’s microwave method, a mechanical method, and scanning electron microscopy.Results:The rat skin exhibited marked variations in collagen fiber orientation among different sites. The direction of the collagen fiber orientation corresponded to that of minimal mechanical strain. We found that the collagen fiber orientation in skin grafts remained almost unchanged after skin grafting.Conclusions:Mismatched collagen fiber orientation between grafts and the surrounding skin is considered to be a cause of secondary contracture after skin grafting. We propose that skin grafts that minimize the difference in collagen fiber orientation between the skin graft and the surrounding skin should be selected.

Transverse vaginal septum managed by simple flap surgery technique: A case report.

BackgroundTransverse Vaginal Septum (TVS) is a rare congenital abnormality, classified as the Mullerian duct anomaly development.1,2 TVS incidence range from 1:2.000 to 1:72.000. Management of TVS may only requirement local excision with a simple end to end anastomosis of the vagina, and use of skin grafts, but this technique has been reported has common complications of secondary tissue contracture, which often lead to stenosis of the vagina.3 In this case we managed TVS with simple flap technique to avoid such postoperative complications and maintain caliber of vagina.CaseA 11 years old girl complained cyclical abdominal pain since a year ago without history of menstrual blood. Patient already had vaginal surgery for removing menstrual blood, but after vaginal surgery the menstrual blood cannot be removed, then referred to our hospital. Ultrasound examination revealed hematometra and hemocolpos. The septum location was 3,38 cm proximal distance from vaginal introitus with the thickness of 8.1 mm. We performed simple excision of the septum with formerly performed distal vaginal septum mucosa preparation creating lateral flaps, then approximating the flaps to the edge of the proximal vaginal mucosa with interrupted suture continued with hymenorraphy. The patient has no complaint 6 months after surgery with vaginal length 8 cm, and had regular menstrual cycle.ConclusionA simple flap surgery technique can be done in transverse vaginal septum, with no complication such as tissue contracture, vaginal stenosis, or insightly scarring. This is a simple technique and can be done with hymenorraphy to restore normal anatomy of hymen.

Nipple Engineering: Maintaining Nipple Geometry with Externally Scaffolded Processed Autologous Costal Cartilage

Nipple reconstruction is the essential last step of breast reconstruction after total mastectomy, resulting in improved general and aesthetic satisfaction. However, most techniques are limited by secondary scar contracture and loss of neo-nipple projection leading to patient dissatisfaction. Approximately, 16,000 patients undergo autologous flap breast reconstruction annually, during which the excised costal cartilage (CC) is discarded. We propose utilizing processed CC placed within biocompatible 3D-printed external scaffolds to generate tissue cylinders that mimic the shape, size and biomechanical properties of native human nipple tissue while mitigating contracture and projection loss. External scaffolds were designed and then 3D-printed using polylactic acid (PLA). Patient-derived CC was processed by mincing or zesting, then packed into the scaffolds, implantedinto nude rats and explanted after3 months for volumetric, histologic and biomechanical analyses. Similar analyses were performed on native human nipple tissue and unprocessed CC. After 3 monthsin vivo,gross analysis demonstrated significantly greater preservation of contour, projection and volume of the scaffolded nipples. Mechanical analysis demonstrated that processing of the cartilage resulted in implant equilibrium modulus values closer to that of the human nipple. Histologic analysis showed the presence of healthy and viable cartilage after 3 months in vivo, invested with fibrovascular tissue. Autologous CC can be processed intraoperatively and placed within biocompatible external scaffolds to mimic the shape and biomechanical properties of the native human nipple. This allows for custom design and fabrication of individualizedengineeredautologousimplants tailored to patientdesire, without the loss of projection seen with traditional approaches.

Features of free skin grafting to correct post-burn neck deformities in children

BACKGROUND: In the literature, various methods of reconstructive plastic surgery for neck cicatricial contractures, from free skin grafting to expander dermotension and microsurgical tissue complex autotransplantation, are widely covered. However, very little attention has been paid to conservative measures aimed at stabilizing surgical treatment results.&#x0D; AIM: This study aims to evaluate the long-term results of free skin grafting of neck granulating wounds after burns and secondary relapsing scar contracture correction. The study also aims to analyze the causes of poor results and demonstrate the possibility of using free skin grafting to correct neck contractures with basic preventive measures.&#x0D; MATERIALS AND METHODS: Forty-six patients with neck burn cicatricial sequelae were treated at the clinic of trauma sequelae in H. Turner National Medical Research Center from 2017 to 2019. The patients were divided into two groups: group 1 patients with neck contractures after plasty of granulating wounds with free skin autografts, and group 2 patients with a relapse of neck contracture after corrective reconstructive surgery.&#x0D; Anamnestic data analysis enabled establishing the actual volume of preventive rehabilitation measures in both patient groups. The classification by N.E. Povstyany (1973) was used to determine the severity of contracture.&#x0D; RESULTS: The most severe neck contractures, grade III and IV, developed in group 1 patients (grade III 41.2%). In group 2 patients, there was a limitation of neck extension, corresponding to grades I (33.3%) and II (58.3%).&#x0D; Conservative preventive measures as immobilization and compression therapy were absent in group 1 in 100% of cases. The most common preventive measure was the prescription of topical anti-scar drugs.&#x0D; Two-stage skin grafting with full-thickness skin autografts combined with conservative measures made it possible to correct neck contractures of grade I-IV completely and obtain good aesthetic results.&#x0D; CONCLUSION: The main reason for neck contractures development is the retraction of skin autografts, which inevitably develops in the absence of appropriate preventive measures.&#x0D; Correction of neck contractures using free skin grafting combined with preventive immobilization using a Schantz collar and a compression half-mask allows obtaining good functional and aesthetic results.