AAHS January 10-13, 2007 ASPN January 13-14, 2007 ASRM January 13-16,2007 PROGRAM B O O K 2007 ANNUAL SCIENTIFIC MEETINGS

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? TABLE OF CONTENTS

AAHS Board of Directors ...... 1 AAHS Committees ...... 2 AAHS Historical Information ...... 3 Hand Endowment Contributor List ...... 4-6 ASPN Council Members ...... 7 ASPN Committees ...... 8 ASPN Historical Information ...... 9 ASRM Council Members ...... 10 ASRM Committees ...... 11-12 ASRM Historical Information ...... 13 (insert tab labeled GENERAL) Messages from the Program Chairs ...... 14 General Announcements ...... 15 Social Events & Tours ...... 16 2007 Exhibitor Listing ...... 17-19 CME Information ...... 20-22 Presenters’ Disclosure Listing ...... 23 Future Annual Meeting Locations ...... 24 (insert tab labeled AAHS) AAHS Wednesday Day-At-A-Glance ...... 25 La Federacion del Mano Inaugural Meeting ...... 26 Bioskills Workshops ...... 26 Specialty Day Program: Rapid Recovery - The Fast Track ...... 27 Specialty Day Program Handouts ...... 27-50 AAHS Thursday Day-At-A-Glance ...... 51 Keynote Speaker: Bob Jamieson ...... 54 AAHS Friday Day-At-A-Glance ...... 55 J. Joseph Danyo Presidential Invited Lecturer: Robert D. Beckenbaugh, MD ...... 56 Comprehensive Review Course ...... 58 AAHS Invited Speaker: Richard Kogan, MD ...... 59 (insert tab labeled AAHS/ASRM/ASPN) AAHS/ASRM/ASPN Saturday Day-at-a-Glance ...... 60 AAHS/ASRM/ASPN Presidents’ Invited Lecturer: Richard H. Gelberman, MD ...... 61 ASRM Masters Series in Microsurgery ...... 62 (insert tab labeled ASPN) ASPN Saturday Day-At-A-Glance ...... 63 Invited Speaker: Prof. Xavier Navarro Acebes, MD, PhD ...... 64 Invited Speaker: Jianguang Xu, MD, PhD ...... 65 Invited Speaker: Prof. Rolfe Birch ...... 65 ASPN Sunday Day-At-A-Glance ...... 66 Invited Speaker: Tessa Gordon, PhD ...... 68 (insert tab labeled ASRM) ASRM Sunday Day-At-A-Glance ...... 71 Godina Lecturer: Ming Huei Cheng, MD, MHA ...... 75 ASRM Monday Day-At-A-Glance ...... 76 ASRM Presidential Invited Lecturer: Ronald M. Zuker, MD, FRCSC, FACS, FAAP ...... 79 Composite Tissue Allotransplantation Update Session ...... 80 ASRM Tuesday Day-At-A-Glance ...... 81 Buncke Lecturer: James Urbaniak, MD ...... 83 (insert tab labeled ABSTRACTS) Abstract Table of Contents ...... 84 2006-2007 AAHS BOARD OF DIRECTORS

President Ronald Palmer, MD President-Elect N. Bradly Meland, MD Vice-President Scott Kozin, MD Secretary A. Lee Osterman, MD FACS Treasurer Richard E. Brown, MD Historian Keith Brandt, MD Parliamentarian Brian Adams, MD

Past Presidents Susan Mackinnon, MD Richard A. Berger, MD, PhD

Directors At Large George Landis, MD Peter Murray, MD Nash Naam, MD Nicholas Vedder, MD

Affiliate Directors Julianne Howell, PT MS CHT Christine Novak, PT MS Aviva Wolff, MA, OTR, CHT

1 AAHS COMMITTEES Please join us in thanking the AAHS committees for their work in 2006.

EDUCATION COMMITTEE Jaiyoung Ryu, MD FACS, Chair Timothy J. Best, MD, MSc, FRCSC Kevin Chung, MD Paula Galaviz, OT Lisa J. Gould, MD, PhD Kevin Plancher, MD Renata Vanja Weber, MD

FINANCE COMMITTEE Richard E. Brown, MD, Chair Susan Mackinnon, MD N. Bradly Meland, MD Ronald Palmer, MD

MEMBERSHIP: ACTIVE COMMITTEE Steven McCabe, MD, Chair John D. Bauer, MD Amy L. Ladd Steven L. Moran, MD Raj Sood, MD Robert Spinner, MD

MEMBERSHIP: AFFILIATE COMMITTEE Carin Jean Wulf, OT, CHT, Chair Gail Groth, OTR/L CHT MHS Rebecca von der Heyde, MS, OTR/L, CHT

NOMINATING COMMITTEE Susan Mackinnon, MD, Chair Maureen Hardy, PT MS CHT M. Ather Mirza, MD Michael Neumeister, MD Warren Schubert, MD William Swartz, MD

PROGRAM COMMITTEE A. Lee Osterman, MD FACS, Chairperson Jorge L. Orbay, MD, Co-Chairperson Randipsingh Bindra, MD Diana D. Carr, MD Kevin Chung, MD M. Ather Mirza, MD Christine Novak, PT MS Kevin Plancher, MD Kirsten Westberg, MD

RESEARCH GRANTS COMMITTEE Michael Neumeister, MD, Chair Matthew A. Bernstein, MD Christine J. Cheng, MD Loree K. Kalliainen, MD, FACS

TECHNOLOGY COMMITTEE George Landis, MD Coleen T. Gately, PT, DPT, MS David Netscher, MD Eric Rothenberg, MD, FACS Stephen Schnall, MD Hugh L. Vu, MD, MPH

2 AAHS HISTORICAL INFORMATION

AAHS PAST PRESIDENTS KEYNOTE SPEAKERS J. Joseph Danyo, MD 1970-1972 William L. White, MD 1978 Henry , MD 1972-1973 John W. Madden, MD 1979 Ray A. Elliott, Jr., MD 1973-1974 Harold E. Kleinert, MD 1980 James Borden, MD 1974-1975 J. William Littler, MD 1981 Kim K. Lie, MD 1975-1976 Clifford C. Snyder, MD 1982 Frank L. Thorne, MD 1976-1977 Lawrence R. Werschky, MD 1977-1978 Robert A. Chase, MD 1983 Robert T. Love, MD 1978-1979 Richard J. Smith, MD 1984 Arnis Freiberg, MD 1979-1980 James M. Hunter, MD 1985 Thomas J. Krizek, MD 1980-1981 Bernard McC. O’Brien, MD 1986 George L. Lucas, MD 1981-1982 Erle E. Peacock, Jr., MD 1988 Garry S. Brody, MD 1982-1983 Michael Jabelay, MD 1989 James G. Hoehn, MD 1983-1984 Robert M. McFarlane, MD 1990 Peter C. Linton, MD 1984-1985 James H. Dobyns, MD 1991 Wallace H.J. Chang, MD 1985-1986 Austin D. Potenza, MD 1986-1987 Adrian E. Flatt, MD 1992 Lee E. Edstrom, MD 1987-1988 John B. Carlson, PhD 1993 C. Lin Puckett, MD 1988-1989 Pat Clyne 1995 Robert J. Demuth, MD 1989-1990 David M. Evans, FRCS 1996 Wyndell H. Merritt, MD 1990-1991 Eugene Nelson, MD 1997 Frederick R. Heckler, MD 1991-1992 Fritz Klein 1998 Robert D. Beckenbaugh, MD 1992-1993 Janet L.Babb 1999 David J. Smith, Jr., MD 1993-1995 Frank E. Jones, MD 2000 James W. May, Jr., MD 1995-1996 Robert H. Brumfield, Jr., MD 1996-1997 Joseph Buckwalter, MD 2001 Robert C. Russell, MD 1997-1998 Linda Cendales, MD 2002 Peter C.amadio, MD 1998-1999 Arnold-Peter Weiss, MD 2003 William M. Swartz, MD 1999-2000 Terry L. Whipple, MD, FACS 2005 William Blair, MD 2000-2001 Jeff Lichtman, MD, PhD 2006 Robert Buchanan, MD 2001-2002 Alan Freeland, MD 2002-2003 Allen Van Beek, MD 2003-2004 CLINICIAN/TEACHER OF THE YEAR Richard Berger, MD 2004-2005 Forst Brown, MD 1995 Susan Mackinnon, MD 2005-2006 Robert Beckenbaugh, MD 1996 James Hoehn, MD 1997 PRESIDENTIAL INVITED LECTURERS Alan Freeland, MD 1998 Harold E. Kleinert, MD 1989 Wyndell Merritt, MD 1999 Arthur C. Rettig, MD 1990 Peteramadio, MD 2000 Paul W. Brand, MD 1991 Anthony DeSantolo, MD 2002 Ronald L. Linschied, MD 1993 Michael Jabaley, MD 2002 Guy Foucher, MD 1995 Maureen Hardy 2002 Michael R. Harrison, MD 1996 Sterling Mutz, MD 2002 Dallas D. Raines 1997 John Texter, MD 1998 Vincent R. Hentz, MD 1999 Nancy Dickey, MD 2000 Michael Wood, MD 2001 Francisco Rosas 2002 Arnold-Peter Weiss, MD 2003 Susan Mackinnon, MD 2004 Elvin Zook, MD 2004 Gavin Menzies 2005

3 HAND SURGERY ENDOWMENT The following companies are recognized as Corporate Sponsors for their generous donations in 2006. Hand Innovations $20,000 Synthes $20,000 American Surgical Centers $2,000 Slack Inc. $1,000

The following individuals are recognized for their ongoing financial commitment to the Hand Surgery Endowment

DIAMOND (Cumulative giving totaling $20,000 or more) W.P. Andrew Lee, MD Alexander Angelides, MD Garry Brody, MD Joseph Danyo, MD William Leighton, MD Mallory Anthony, RPT Linda Brown, ND Alan Freeland, MD JoAnn Levitan, MD John Anton, MD Mary Lynn Brown, MD Robert Schenck, MD Kim Lie, MD Dori Ann Appleman, OTR,CHT Roger Brown, MD Ho Min Lim, MD Thomas Arganese, MD Robert Brumfield, MD Shelia Lindley, MD Enrique Armenta, MD Mark Buchman, MD EMERALD Robert Love, MD William Armiger, MF Robert Buckley, MD (Cumulative giving up to $10,000) George Lucas, MD Laurence Arnold, MD Geoffrey Buncke, MD N. Bradly Meland, MD Susan Mackinnon, MD Michael Aron, MD Gregory Buncke, MD Ronald Palmer, MD James May, Jr., MD Kenneth Arthur, MD Kim Buchstaber, OTR Miguel Saldana, MD W. R. McArthur, MD Tyrone Artz, MD Rudolf Buntic, MD James Schlenker, MD Vaughn Meyer, MD Stanley Askin, MD Mary Burns, OTR/L,CHT Susan Michlovitz, PT, PhD Edward Athanasian, MD Christine Burridge, PT, CHT Ather Mirza, MD John Attwood, MD Vincent Butera, MD RUBY Hiram Morgan, MD John Aversa, MD Marcia Buzzelli, PT, MS (Cumulative giving up to $5,000) Nash Naam, MD Samir Azer, MD Carmine Calabrese, MD Anthony Brown, MD Daniel Nagle, MD Medhi Balakhani, MD Elethea Caldwell, MD Ali Seif, MD A Lee Osterman, MD Joyce Baldwin, OTR/L, CHT Catherine Calvey Allen Van Beek, MD Edward Palmer, MD George Balfour, MD Michael Campbell Swainathan Rajan, MD Brent Bamberger. MD Nancy Cannon, OTR, CHT Norman Rappaport, MD Adel Barakat, MD David Caplin, MD SAPPHIRE Jaiyoung Ryu, MD John Barham, MD James Carey, MD (Cumulative giving up to $3,000) Amorn Salyapongse, MD David Barker, MD Ronaldo Carneiro, MD Stephan Ariyan, MD Somprasong Songcharoen, MD Bruce Barton, MD Ann Carrillo, OTR Mark Baratz, MD William Swartz, MD M. L. Barton, MD Glenn Carwell, MD Rocco Barbieri, MD Nicholas Vedder, MD Lynn Bassini, OTR, CHT Phyllis Chang, MD John Bax, MD Eric Wegener, MD Basilio Bautista, MD Wallace Chang, MD William Benson, MD Michael White, MD Carlos Bazan, MD James Chao, MD Beth Ann Bergman, MD Eric Wyble, MD Michael Beatty, MD John Chapple, MD Phillip Blevins, MD Robert Beckenbaugh, MD Lawrence Chase, MD Forst Brown, MD TOPAZ Lawrence Bell, MD Andre Chaves, MD Richard Brown, MD (Cumulative giving of $1,000) Keith Bengtson, MD Eugene Cherny, MD William Brown, MD Louis Benoist, MD Vradej Chinookoswong, MD Robert Buchanan, MD Alejandro Badia, MD Leon Benson, MD Raj Chowdary, MD A. Lawrence Cervino, MD Kyle Bickel, MD David Bierwagen, PT, CHT Robert Chuinard, MD David T.W. Chiu, MD Randy Bindra, MD David Bikoff, MD Duke Chung, MD Jerry Chow, MD Robert Costarella, MD David Billmore, MD Michael Clark, MD James Clayton, MD Richard Demuth, MD David Birkbeck, MD Michael Clendenin, MD Mark Cohen, MD Michael Kalisman, MD Roderick Birnie, MD June Clopton, MD David Conner, MD Albert Weiss, MD Allen Bishop, MD Tyson Cobb, MD James Cullington, MD Donald Bittner, MD Roberta Cohen, OTR Donald Ditmars, MD HONOR ROLL William Blair, MD Richard Coin, MD Richard Fox, MD (Cumulative giving less than $1,000) Elizabeth Blake, MD Larry Colen, MD Felix Freshwater, MD Donna Blood, OTR/L, CHT Lee Colony, MD Dorit Aaron, MA, OTR,CHT Robert Gardere, MD Richard Bloomenstein, MD Charles Combs, MD Govind Acharya, MD Leonard Bodell, MF Michelen Craft-Maynor William Geissler, MD Brian Adams, MD Neil Green, MD Lisa Adams, CVE, CHT Maria Bonazinga Lester Cramer, MD Robert Harris, MD Medhi Adham, MD Michael Born, MD Evan Crandall, MD Fred Heckler, MD Galaa Agban, MD William Boss, MD Gregory Croll, MD David Hildreth, MD Joseph Agris, MD Lawrence Bowen, MD Terry Cromwell, MD James Hoehn, MD John Alipit, MD David Bozentka, MD Robert Crow, MD Peter Hui, MD Bernard Alpert, MD Timothy Bradley, MD Bohdan Czepak, MD Richard Idler, MD Peteramadio, MD Keith Brandt, MD Suman Das, MD Ted Jackson, MD Chittur Ananthakrishnan, MD Nancy Branz, PT, MS Brian Davies, MD Ronald Joseph, MD Dimitri Anastakis, MD Laurence Brenner, MD Bert Davis, MD Scott Kozin, MD William Anderson, MD Anthony Brentlinger, MD Jayne Dederichs, OTR/L George Landis, MD Cary Andras, MD Bruce Brewer, MD Fanny De le Cruz, MD John Lang, MD Michael Angel, MD James Brinkman, MD A. Lee Dellon, MD

4 HONOR ROLL CON’T Terry Fillian, MD William Jones, MD Alexander Majidian, MD Kenn Given, MS Jesse Jupiter, MD Matthew Malerich, MD Heather Delp, LPT Lawrence Glassman, MD Ramasamy Kalimuthu, MD Parvaiz Malik, MD Jack Demos, MD Shellye Godfrey, OTR/L, CDE, CHT Loree Kalliainen Stephen Maloff, MD Gloria DeOlarte, MD Alan Gold, MD Ann Kammien, PT Christopher Maloney, MD Michael DePriest, MD Nelson Godlberg, MD Shin Kang, MD Harold Mancusi-Ungaro, MD Robin De rose, OTR Stephen Goldstein, MD Reza Karimipour, MD Mark Mandel, MD Robert Derkash, MD Gregg Godnstrom, MD Scott Kasden, MD John Mara, MD Sanjay Desai, MD Federico Gonzalez, MD Martin Kassan, MD Hallene Maragh, MD Antonio DeSantolo, MD Marc Gottlieb, MD Joanne Kassimir, CHT, OTR Norberto Marfori, MD Susan DeStefano, OTR/L Joel Grad, MD Gloria De Vore, OTR Richard Katz, MD Andrew Markiewitz, MD Gene Deune, MD Wendell Gray, MD Mark Kehn, MD James Marshall, MD Thomas DeWire, MD Lawrence Gray, MD Patrick Kelly, MD Kenneth Marshall, MD Prabhu Dhalla, MD Daniel Greenwald, MD Mark Kendall, MD David Martin, MD Michal Diaz, MD Jack Greider, MD Carolyn Kerrigan, MD Rosendo Martinez, MD Thomas DiBenedetto, MD John Griggs, MD Martin Kessler, MD Nalin Master, MD Wayne Dickason, MD John Grossman, MD Lawrence Ketch, MD Howard Matsuba, MD John Dietrich, MD Gail Groth, OTR/L, CHT, MHS Roger Khouri, MD William Mayhall, MD Joseph Disa, MD Amit Gupta, MD Suheil Khuri, MD Alexander McArthur, MD Susan Doehr, OTR Roxanne Guy, MD Kyo Kim, MD John McAvoy, MD Sam Dovelle, OTR Mutaz Habal, MD Myung Kim, MD Steven McCabe, MD Gregory Dowbak, MD Jane Haher, MD Woo-Kyung Kim, MD Thomas McChesney, MD David Drake, MD Paul Haiduk, MD Yong Kim, MD Pamela McFarlane, MA, OTR, CHT John Drewniany, MD Geoffrey Hallock, MD Charles Kincaid, MD John McGill, MD Marc Drimmer, MD Michael Halls, MD Gabriel Kind, MD Nancy McHugh, OTR/L Gale DuPont, OTR/L Yousif Hamati, MD Eugene King Craig McKee, MD William Dzwierzynski, MD Robert Hansen, MD Lynn King, OTR, CHT Mehul Mehta, MD Janice Eaton, OTR/L, CHT Paul Harkins, MD John Kitzmiller, MD Keith Melancon, MD Charles Eaton, MD Richard Harkness, MD Howard Klein, MD Mark Melhorn, MD Herbert Ecker, MD William Hart, MD Richard Knauft, MD Charles Melone, MD Lee Edstrom , MD Thomas Harter, MD Todd Koch, MD Jayasanker Menon, MD Robert Ellis, MD David Haskell, MD Richard Korentager, MD Craig Merrell, MD James Esch, MD Christopher Hauge, MD Bruce Kraemer, MD Wyndell Merritt, MD Gregory Evans, MD Chester Haverback, MD David Kupfer, MD Louis Mes, MD John Faillace, MD Robert Havlik, MD Mine Kurtay, MD Philip Metz, MD John Fatti, MD Tom Hayakawa, MD Stuart Kuschner, MD Claudia Meuli-Simmen, MD Bohdan Fedczuk, MD John Heieck, MD Joe Kutz, MD John Miller, MD Harodl Fenner, MD Darrell Henderson, MD Jean Labelle, MD Fred Miller, MD Mciahel Ferdinands, MD Douglas Hendricks, MD Daniel Labs, MD Norbert Ming, MD John Finley, MD Karen Henehan, MD Juanita Laflin, CST Sinesio Misol, MD David Fischer, MD Charles Hergrueter, MD John Lamana, MD Jose Monsivais, MD Gregory Fisher, MD Ralph Herms, MD Lauren Lancaster Carlos Montero, MD Stephen Fisher, MD Gregory Hill, MD Richard Landry, MD Kenneth Moore, MD David Fitz, MD Blayne Hirche, MD Ann Lang, MA, OTR, CHT William Moore, MD Richard Flaherty, MD Christine Hoban, OTR, CHT Edward Lanigan, MD Seid Moosavi, MD Sandra Fletchall, OTR CHT, MPA Leslie Holcombe, OTR, CHT Mary Beth Laplant, LPT Thomas Mordick, MD Michael Flood, MD Ellen Horvitz, MS, PT, CHT Donald Leatherwood, MD Richard Morgan, MD Waldo Floyd, MD Barney Horvath, MD Peter Ledoux, MD Donald Morris, MD Martin Fox, MD Arden Hothem, MD Charles Lee, MD Stephen Morris, MD Paul Fragner, MD Homer House, MD Hans Lee, MD Robert Morrison, MD Arnis Freiberg, MD Patrick Houvet, MD Howard Lee, MD Keith Morrison, MD Scott Fried, MD Lon Howard, MD James Lehman, MD Robert Morrow, MD Jeff Friedman, MD Pamela Howard, PT Charles Leinberry, MD Kenneth Murray, MD Mia Fuller, MS, OTR, CHT Richard Howard, MD Lori Lenef, OTR/L Peter Murray, MD Stephen Fuller, MD David Huang, MD Carl Lentz, MD Eid Mustafa, MD Gerard Gabel, MD Mary Hubbell, CHT, CWCE Malcolm Lesavoy, MD Stephen Naso, MD Unmeshchandra Gadaria, MD William Huffaker, MD Mark Leslie, MD Chet Nastala, MD Sylvia Gagnon, MD Edward Hughes, Jr., MD John Lettieri, MD Peter Nathan, MD Paula Galaviz, OT Thomas Hunt, MD Scott Levin, MD Michael Neumeister, MD Randi Galli, MD Kenneth Hunter, MD Richard Levin, MD Andrew Newman, MD Peter Galpin, MD Mary Isaacson, OTR George Levine, MD Frank Newman, MD Greg Ganske, MD Cindy Ivy, CHT Carolyn Levis, MD Mary Lynn Newport, MD Carlos Garcia Moral, MD Deborah Jacob-Maas Jonathon Lewis, MD William Nickell, MD Walter Garst, MD Marshall Jemison, MD Terry Light, MD Thomas Nipper, MD William Garvin, MD Chet Janecki, MD Peter Linden, MD Christine Novak, MD Shelai Gassler, OTR, CHT Raymond Janevicius, MD John Lindsey, MD Renee O’Sullivan, MD Trenton Gause, MD David Janssen, MD Charles Loguda, MD William Ogden, MD Eusebio Gaw, MD M.R. Jayasanker, MD Linda Loya, MA, OTR,CHT Walter Okunski, MD Michael Genoff, MD David Jensen, MD Karen Luckett, OTR, CHT Elizabeth Ouellette, MD Margaret Geringer, OTR Theron Jernigan, PT Steven Macht, MD Winston Parkhill, MD Gunter Germann, MD Stiles Jewett, MD Joy MacDermid, MD Douglas Parks, MD Royal Gerow, MD Craig Johnson, MD Douglas Mackenzie, MD Samuel Parry, MD Marilyn Giln, OTR, CHT Susan Johnson-Melat, OTR, CHT/CVE Larry Maddy, RN, OTR/L, CHT Jay Patel, MD

5 HONOR ROLL CON’T Will Schlaff, MD Joseph Upton, MD Linda Schoenhals, MS, RPT James Urbaniak, MD Norman Payea, MD Anne Schofield, OTR/L,CHT Frederick Valauri, MD Shirley Pearson, OTR, MS Warren Schubert, MD Napoleon Valdez, MD Edward Pechter, MD Frank Schuler, MD David Van Brunt, MD William Pederson, MD Karen Schultz, MS, OTR, CHT Robert Van Demark, MD Joseph Perlman, MD Timothy Schurman, MD Peter Van Giesen, MD James Pertsch, MD John Seaberg, MD Scott Vann, MD Mary Son Pesco, MD Kristin Seabol, MD Benjamin Van Raalte, MD Donald Pfeiffer, MD Houshang Seradge, MD George Veasy, MD Howard Philips, MD Donald Serafin, MD Tina Veraldi, OTR, CHT Guy Pierret, MD Jacob Sharp, MD Nicholas Vienowicz, MD Alan Pillersdorf, MD Jean Pilllet, MD Jay Shenaq, MD Charles Verheyden, MD James Pinkham, MD Saleh Shenaq, MD Jeffrey Visotsky, MD Miguel Pirella-Cruz, MD Randolph Sherman, MD Thomas Von Gillern, MD Subbarao Polineni, MD Kenneth Shestak, MD Frank Walchak, MD Jay Pomerance, MD Sung Shin, MD Lorenzo Walker, MD Barry Poole, OTR, CHT Raymond Shively, MD William Wallace, MD Rasa Poorman, OTR, CHT J.F. Showalter, MD Madlyn Walton, OTR, CHT Edward Powers, MD Aamir Siddiqui, MD Robert Walton, MD Julian Pribaz, MD Jessica Siegers, OTR/L Huan Wang, MD George Primiano, MD Maria Siemionow, MD Robert Wanless, MD Sergio Proserpi, MD Roger Simpson, MD Robert Waterhouse, MD Talmage Raine, MD Martin Skie, MD Paul Wavak, MD Oscar Ramirez, MD Joesph Slade, MD Burton Weber, MD Lorna Ramos, MA, OT Paul Slater, MD Donald Wehmeyer, MD James Raphael, MD Anthony Smith, MD Larry Weinstein, MD Georg Rappold, MD Dell Parker Smith, MD Beth Weiss, OTR Gregory Rauscher, MD Raymond Smith, MD Mark Wells, MD Vincent Reale, MD Bendy So, MD Terry Westfield, MD Larry Reaves, MD Roger Sobel, MD Linda Westphal, OTR/L Michael Reed, MD Norman Sogioka, MD Michael Wheatley, MD Loka Reddy, MD Raj Sood, MD John Wheeler, MD David Rehak, MD Dean Sotereanos, MD Nick Wheeler, MD Michael Rench, MD John Sparrow, MD Richard Whipple, MD Kevin Renfree, MD Jerome Spivack, MD Carolyn White Charles Renner, OTR T. Sreecharana, MD David White, MD Charles Resnick, MD James Stafford, MD Richard White, MD William Reus, MD William Starr, MD David Whiteman, MD Mary Reuterfors, MA, OTR, CHT J. Stayman, MD Robert Wilcox, MD Scott Riley, MD Scott Steinmann, MD Brandon Wilhelmi, MD William Riley, Jr., MD Charlene Stennett, MD Carl Williams, MD Jeff Robb, MD Peter Stern, MD Barbara Winthrop-Rose, OTR, CHT Bradford Roberg, MD Michael Sternschein, MD Edward Withers, MD Dwight Roberson, MD Thomas Stevenson, MD Eugene Wittenstrom, MD Craig Roberts, MD Curtis Steyers, MD David Witzke, MD Celia Robinson, MA, PT, CHT Harold Stokes, MD Levent Yalcin, MD John Robinson, MD Mary Stoliker, MS, OTR, CHT Scott Young, MD Alfredo Rodriguez, MD Tristan Stronger, MD John Yousif, MD Frank Rogers, MD Kevin Strathy, MD William Zamboni, MD Allen Rosen, MD Berish Strauch, MD Jerrold Zeitels, MD Arthur Rosenstock, MD William Strinden, MD Michael Zenn, MD Douglas Ross, MD Chi-Tsung Su, MD D. Ziarkowski-Herb, PT, CHT Malcolm Roth, MD John Swinburne, MD Paul Zidel, MD Eric Rothenberg, MD Raymond Takahashi, MD Richard Zienowicz, MD Paul Rottler, MD John Taras, MD Elvin Zook, MD Leo Rozmaryn, MD Julia Terzis, MD Ronald Rusko, MD Howard Tepper, MD Robert Russell, MD Ben Thebaut, MD Scott Sagerman, MD Lawrence Thompson, MD Harilaos Sakellarides, MD Grant Thomson, MD Chester Sakura, MD James Thornton, MD Jeffrey Salomon, MD Jennifer Thurn, OTR, CHT Mona Samaan David Toivonen, MD Alejandro Sanchez, MD Bruce Topol, MD Richard Sanders, MD Steven Topper, MD Gordon Sasaki, MD Allen Tracy, MD Sandra Saunders, RPT, PT, CHT Richard Troiano, MD Robert Savage, MD Deborah Trojanowski, MD Linda Schaffstall, OTR/L, CHT Thomas Trumble, MD John Schantz, MD Robert Tucker, MD James Scheu, MD Tsu Tsai, MD Kenneth Schiffman, MD Christopher Ubinger, MD

6 2006-2007 ASPN COUNCIL

President Rajiv Midha, MD President-Elect Gregory R. D. Evans, MD, FACS Vice President Robert C. Russell, MD Secretary Howard M. Clarke, MD, PhD Treasurer Warren Schubert, MD Immediate Past President Maria Siemionow, MD, PhD Past President Steven McCabe, MD Historian Paul S. Cederna, MD Council Member at Large Ivica Ducic, MD, PhD Council Member at Large Allan J. Belzberg, MD Council Member at Large Thomas H.H. Tung, MD

7 ASPN COMMITTEES Please join us in thanking the following ASPN committees who have helped make the 2006-year successful.

PROGRAM COMMITTEE EDUCATION COMMITTEE Robert Spinner, MD, Chairperson Dimitri Anastakis, MD, Chairperson Joseph Rosen, MD A. Lee Dellon, MD Nash Naam, MD Robert Spinner, MD Ivica Ducic, MD, PhD Rajiv Midha, MD, Ex-Officio David Netscher, MD Melanie Urbanchek, PhD TIME AND PLACE COMMITTEE Peter Evans, MD Robert Russell, MD, Chairperson David Weinstein, MD, PhD Maria Siemionow, MD, PhD Nancy McKee, MD, FRCSC Gregory R. D. Evans, MD, FACS Jose Monsivais, MD Thomas Tung, MD Martijn Malessy, MD, PhD Steven McCabe, MD Robert Tiel, MD Rajiv Midha, MD Rajiv Midha, MD, Ex-Officio Allan Belzberg, MD Howard M. Clarke, MD, PhD MEMBERSHIP COMMITTEE Warren Schubert, MD Gregory R. D. Evans, MD, FACS, Chairperson Paul Cederna, MD Howard M. Clarke, MD, PhD Ivica Ducic, MD, PhD Jose Monsivais, MD Warren Hammert, DDS, MD NEWSLETTER COMMITTEE Rajiv Midha, MD, Ex-Officio Nash Naam, MD, Editor Robert Spinner, MD, Assistant Editor NOMINATING COMMITTEE Christine Novak, PT, MS, Assistant Editor Maria Siemionow, MD, PhD, Chairperson Allan Belzberg, MD WEB SITE COMMITTEE Martijn Malessy, MD, PhD Paul Cederna, MD, Chairperson Warren Schubert, MD David Brown, MD, FACS Jonathan Winograd, MD Rajiv Midha, MD Steven McCabe, MD, Ex-Officio BYLAWS COMMITTEE CODING AND REIMBURSEMENT COMMITTEE Keith Brandt, MD Melanie Urbanchek, PhD, Chairperson Paul Cederna, MD Loree Kalliainen, MD William Kuzon, MD, PhD Warren Schubert, MD Rajiv Midha, MD, Ex- Officio FINANCE COMMITTEE Robert Russell, MD, Chairperson Martijn Malessy, MD, PhD Thomas Tung, MD Rajiv Midha, MD, Ex-Officio TECHNICAL EXHIBITS COMMITTEE Gregory R. D. Evans, MD, FACS, Chairperson William Kuzon, MD, PhD Robert Spinner, MD Rajiv Midha, MD, Ex-Officio

8 ASPN HISTORICAL INFORMATION

FOUNDING COUNCIL (Established April 19, 1990) Warren Breidenbach, MD Thomas Brushart, MD David Chiu, MD A. Lee Dellon, MD Richard Ehrlichman, MD Nelson Goldberg, MD Roger Khouri, MD Howard Klein, MD Susan Mackinnon, MD Hallene Maragh, MD Wyndell Merritt, MD Michael Orgel, MD Elliot Rose, MD Joseph Rosen, MD Brooke Seckel, MD Saleh Shenaq, MD Thomas Stevenson, MD Berish Strauch, MD Julia K.Terzis, MD, PhD Allen Van Beek, MD H. Bruce Williams, MD

ASPN PAST PRESIDENTS Julia K. Terzis, MD, PhD 1990-1992 A. Lee Dellon, MD 1992-1993 Berish Strauch, MD 1993-1994 H. Bruce Williams, MD 1994-1995 Susan E. Mackinnon, MD 1995-1996 Wyndell Merritt, MD 1996-1997 Allen Van Beek, MD 1997-1998 Saleh Shenaq, MD 1998-1999 David T. W. Chiu, MD 1999-2001 Nancy H. McKee, MD 2001-2002 William M. Kuzon, Jr., MD, PhD 2002-2003 Keith E. Brandt, MD 2003-2004 Steven McCabe, MD 2004-2005 Maria Siemionow, MD, PhD 2005-2006

9 2006-2007 ASRM EXECUTIVE COUNCIL MEMBERS

President L. Scott Levin, MD, FACS President-Elect Lawrence B. Colen, MD Vice-President A. Lee Dellon, MD Secretary Peter C. Neligan, MD Treasurer Keith E. Brandt, MD Treasurer-Elect Joseph M. Serletti, MD, FACS Immediate Past President William C. Pederson, MD

Senior Members-At-Large Gregory R. D. Evans, MD, FACS Michael W. Neumeister, MD

Junior Members-At-Large Charles E. Butler, MD Alexander Y. Shin, MD Historian Neil F. Jones, MD

10 ASRM COMMITTEES Please join us in thanking the following ASRM committees who have helped make the 2006-year successful.

ABPS REPRESENTATIVE AD HOC MICROSURGICAL L. Scott Levin, MD, FACS RESEARCH COMMITTEE Maria Siemionow, MD, PhD, Chairperson AD HOC BREAST COMMITTEE A. Lee Dellon, MD Joseph M. Serletti, MD, FACS, Chairperson Neil F Jones, MD Elisabeth K. Beahm, MD Peter C. Neligan, MD Neil A. Fine, MD, FACS Michael W. Neumeister, MD Maurice Nahabedian, MD Geoffrey L. Robb, MD Aldona J. Spiegel, MD Michael R. Zenn, MD AD HOC OUTREACH COMMITTEE Randy Sherman, MD, Chairperson Gunter Germann, MD AD HOC COMMITTEE ON COMPLEX L. Scott Levin, MD, FACS RECONSTRUCTION Robert C. Russell, MD Fu-Chan Wei, MD, FACS Fu-Chan Wei, MD, FACS, Chairperson Lawrence B. Colen, MD Gunter Germann, MD William C. Pederson, MD AD HOC UPPER EXTREMITY Julian J. Pribaz, MD Milan Stevanovic, MD COMMITTEE Nicholas B. Vedder, MD, Chairperson Warren Breidenbach, MD AD HOC COMMITTEE ON COMPOSITE Gunter Germann, MD TISSUE ALLOTRANSPLANTATION Jonathan Isaacs, MD Neil F Jones, MD Robert L. Walton, MD, FACS, Chairperson A. Lee Dellon, MD Neil F Jones, MD L. Scott Levin, MD, FACS ASPS BOARD REPRESENTATIVE Susan E. Mackinnon, MD Maria Siemionow, MD, Ph.D. Robert L. Walton, MD, FACS Thomas Tung, MD Fu-Chan Wei, MD, FACS AUDIT COMMITTEE AD HOC COMMITTEE ON GENITOURINARY Jeffrey D. Friedman, MD, Chairperson Elisabeth K. Beahm, MD RECONSTRUCTION Michael R. Zenn, MD Lawrence B. Colen, MD, Chairperson Charles E Butler, MD David W. Chang, MD BUNCKE LECTURESHIP COMMITTEE William C. Pederson, MD, Chairperson AD HOC HEAD & NECK David W. Chang, MD L. Scott Levin, MD, FACS SUBSPECIALITY COMMITTEE Geoffrey L. Robb, MD Peter G. Cordeiro, MD, Chairperson G. Ian Taylor, AO, FRACS, FACS FRCS Lawrence J. Gottlieb, MD Michael R. Zenn, MD Michael Miller, MD Julian J. Pribaz, MD BYLAWS COMMITTEE AD HOC LOWER EXTREMITY Julian J. Pribaz, MD, Chairperson SUBSPECIALITY COMMITTEE Gregory M. Buncke, MD Anthony A. Smith, MD L. Scott Levin, MD, FACS, Chairperson Christopher Attinger, MD Marko Bumbasirevic, MD Raymond M. Dunn, MD CLINICAL GUIDELINES & OUTCOMES COMMITTEE AD HOC MEDIA RELATIONS COMMITTEE Nicholas B. Vedder, MD, Chairperson L. Scott Levin, MD, FACS, Chairperson Howard N. Langstein, MD Maria Siemionow, MD, Ph.D. Peter C. Neligan, MD Allen L. Van Beek, MD Michael W. Neumeister, MD

11 ASRM COMMITTEES CON’T

CPT/RUC COMMITTEE NOMINATING COMMITTEE Keith E. Brandt, MD, Chairperson William C. Pederson, MD, Chairperson Gregory M. Buncke, MD Allen T. Bishop, MD Raymond M. Dunn, MD David W. Chang, MD Daniel J. Nagle, MD Gunter Germann, MD Scott D. Oates, MD Robert C. Russell, MD William C. Pederson, MD Michael R. Zenn, MD PROGRAM COMMITTEE Michael R. Zenn, MD, Chairperson EDUCATION COMMITTEE Joseph M. Serletti, MD, FACS, Ex-Officio Howard N. Langstein, MD, Chairperson Elisabeth K. Beahm, MD Paul S. Cederna, MD, FACS Allen T. Bishop, MD Neil A. Fine, MD, FACS Gunter Germann, MD Maria Siemionow, MD, Ph.D. Gabriel M. Kind, MD Alexander Y. Shin, MD Milan Stevanovic, MD ELECTRONIC COMMUNICATIONS Joseph Upton, MD COMMITTEE Charles E Butler, MD, Chairperson PSEF REPRESENTATIVE Keith E. Brandt, MD, Ex-Officio William Dzwierzynski, MD Gregory R.D. Evans, MD, FACS Howard N. Langstein, MD Peter Murray, MD TECHNICAL EXHIBITS COMMITTEE Peter C. Neligan, MD, Chairperson L. Scott Levin, MD, FACS ENDOWMENT COMMITTEE William Lineaweaver, MD Robert L. Walton, MD, FACS, Chairperson Keith E. Brandt, MD Joseph James Disa, MD TIME & PLACE COMMITTEE William A. Zamboni, MD William C. Pederson, MD, Chairperson Robert L. Walton, MD, FACS FINANCE COMMITTEE Ronald M. Zuker, MD, FRCSC Lawrence B. Colen, MD, Chairperson Keith E. Brandt, MD, Ex-Officio Frederick J. Duffy, Jr, MD Joseph M. Serletti, MD, FACS

GODINA FELLOWSHIP SELECTION COMMITTEE Lawrence B. Colen, MD, Chairperson Zoran M. Arnez, MD, PhD David W. Chang, MD L. Scott Levin, MD, FACS Peter C. Neligan, MD

MEMBERSHIP COMMITTEE Lawrence B. Colen, MD, Chairperson A. Lee Dellon, MD, Ex-Officio Elisabeth K. Beahm, MD Gabriel M. Kind, MD Peter Murray, MD Milan Stevanovic, MD

12 ASRM HISTORICAL INFORMATION 1983 FOUNDING COUNCIL James B. Steichen, MD Berish Strauch, MD Julia K. Terzis, MD, PhD James R. Urbaniak, MD Allen L. Van Beek, MD

YEAR PRESIDENT ANNUAL MEETING SITE FOUNDERS/GODINA LECTURERS 1985 Berish Strauch, MD Las Vegas, NV Henry J. Buncke, MD Founders’ Lecturer 1986 James R. Urbaniak, MD New Orleans, LA Harold E. Kleinert, MD Founders’ Lecturer 1987 Joseph E. Kutz, MD San Antonio, TX Robert D. Acland, MD Founders’ Lecturer 1988 H. Bruce Williams, MD Baltimore, MD Berish Strauch, MD Founders’ Lecturer 1989 James B. Steichen, MD Seattle, WA G. Ian Taylor, FRCS, FRACS Founders’ Lecturer 1990 Allen L. Van Beek, MD Toronto, Ontario, Canada Andrew Lightbody Founders’ Lecturer 1991 Michael B. Wood, MD Orlando, FL Alain Gilbert, MD Founders’ Lecturer 1992 Andrew J. Weiland, MD Scottsdale, AZ Edgar Biemer, MD Founders’ Lecturer 1993 Graham Lister, MD Kansas City, MO Algimantas Narakas Founders’ Lecturer Lawrence B. Colen, MD Godina Lecturer 1994-95 Robert C. Russell, MD Marco Island, FL Nguyen Huy Phan, MD Founders’ Lecturer Mark A. Schusterman, MD Godina Lecturer 1995-96 Ralph T. Manktelow, MD Tucson, AZ Fu Chan Wei, MD Founders’ Lecturer Randy Sherman, MD Godina Lecturer 1996-97 James A. Nunley, MD Boca Raton, FL James R. Urbaniak, MD Founders’ Lecturer Zoran M. Arnez, MD Godina Lecturer 1997-98 William M. Swartz, MD Scottsdale, AZ H. Bruce Williams, MD Founders’ Lecturer L. Scott Levin, MD Godina Lecturer 1998-99 David T. W. Chiu, MD Waikoloa, HI Julia K. Terzis, MD Founders’ Lecturer Phillip Blondeel, MD Godina Lecturer 1999-2000 Daniel Nagle, MD Miami, FL Allen Van Beek , MD Founders’ Lecturer Gregory R. D. Evans, MD Godina Lecturer 2000-2001 Saleh M. Shenaq, MD San Diego, CA Wayne Morrision, MD, FRACS Founders’ Lecturer Roger Khouri, MD Godina Lecturer 2001-2002 Randy Sherman, MD Cancun, Mexico Robert Russell, MD Founders’ Lecturer William Zamboni, MD Godina Lecturer 2002-2003 Julia K. Terzis, MD, PhD Kauai, HI Panayotis Soucacos, MD Founders’ Lecturer Raymond Dunn, MD Godina Lecturer 2003-2004 Ronald M. Zuker, MD Palm Springs, CA Ralph Manktelow, MD Founders’ Lecturer Milomir Ninkovic, MD, PhD Godina Lecturer 2004-2005 Robert L. Walton, MD, FACS Fajardo, Puerto Rico Isao Koshima, MD Founders’ Lecturer Michael Neumeister, MD, FRCSC, FACS Godina Lecturer 2005-2006 William C. Pederson, MD Tucson, AZ David Chang, MD, FACS Godina Lecturer

13 MESSAGES FROM THE PROGRAM CHAIRS AAHS The 2007 annual meeting of the American Association for Hand Surgery will be held at the Westin Rio Mar Beach Golf Resort and Spa in Puerto Rico from January 10 to 13, 2007. The theme is Hand Treasures of the Caribbean and promises the attendee an adventurer’s chest of clinical pearls, educational rubies, diamonds of friendship, and exciting nuggets of gold. The program begins on Wednesday, January 10 with a speciality day program emphasizing the techniques that insure rapid recovery from hand and wrist injuries. The afternoon lets you rate your golf swing against a pro, take a bioskills course, and enjoy the amenities of the resort. Save your energy for the welcome reception that night. Thursday, January 11, begins bright and early with six instructional courses, a panel on the Evolution of the Hand, chaired by Amy Ladd, MD and featuring noted anthropologist Mary Marzke, PhD and neurologist Frank Wilson, MD author of The Hand: How its use shapes the Brain. Richard A. Berger, MD, PhD updates the state of wrist and hand prostheses. After free papers, the morning session concludes with the keynote speaker, Bob Jamison, ABC national and former White House correspondent. Following lunch, the learning opportunities continue with six more ICLs and an update on coding strategies by Daniel Nagle, MD. Friday, January 12, continues the adventure with six more ICLs, dual free paper sessions, a panel challenging the experts on distal radius fracture cases, and two keynote lectures by Robert D. Beckenbaugh, MD and Eduardo Zancolli III, MD. The afternoon is dedicated to Peter Murray, MD’s popular Comprehensive Hand Surgery Review that updates every aspect of hand surgery. Friday evening is not to be missed. It begins with a performance by Richard Kogan, MD, a psychiatrist and concert pianist who analyzes the tortured creativity of Gershwin through his letters, medical problems, and music. Step directly from there into the AAHS dinner dance and party that would make the Pirates of the Caribbean jealous. Saturday, January 13, is our collaborative program with the American Society for Reconstructive Microsurgery and the American Society for Peripheral Nerve. Panels include Upper Extremity Injury in Modern Warfare detailing the recent advances in caring for severe extremity wounds and a Brachial Plexus panel full of practical management tips and nerve transfer specifics. Richard Gelberman, MD will be the Presidents’ keynote speaker. The afternoon golf tournament underlines the fact that outside your front door there are championship golf, tennis, multiple pools, and an ocean beach. When feeling less athletic, enjoy the world class spa, five gourmet restaurants, and casino. Close by, explore the natural beauty of El Yunque rain forest, visit the forts of Old San Juan, and salsa dance to the Latin nightlife. Thank you for being a part of this exciting, educational, and enjoyable experience.

A. Lee Osterman, MD Jorge L. Orbay, MD AAHS 2007 Program Chair AAHS 2007 Program Co-Chair ASPN

Thank you for attending the 16th annual American Society for Peripheral Nerve scientific meeting at the luxurious Westin Rio Mar Beach Resort in Rio Grande, Puerto Rico. On Saturday morning, joint sessions with the AAHS and ASRM will convene. A panel on Upper Extremity Injuries in Modern Warfare will begin the conference. Dr. Richard Gelberman will deliver the Presidents Invited Lecture on: Identifying Targets for Clinical and Research Excellence in 2007. Outstanding nerve papers from the 3 societies will be presented. A panel of international experts will review new trends and perspectives in Brachial Plexus Surgery 2007. Saturday afternoon will include 3 invited speakers: Xavier Navarro Acebes on Tube Repair: Advances Towards an Artificial Nerve Graft; Jianguang Xu on C7 Nerve Transfer: Past, Present, Future; and Rolfe Birch on Iatropathic Injuries of Peripheral Nerves. There will be one session with clinical and research papers. On Sunday, a host of instructional courses will start off the day: on brachial plexus birth palsy, cortical reorganization, reinnervating muscle, peripheral nerve tumors, and intraoperative monitoring. An ASRM/ASPN panel on Free Functioning Muscle Transfer is planned. Invited Speaker Tessa Gordon will discuss Emerging Strategies to Improve Outcome of Nerve Injury. Free papers will be admixed in the morning and afternoon sessions. In addition to the outstanding scientific program, a lively social agenda and beautiful weather is being forecasted. The ASPN Welcome Reception on Saturday evening will foster informal interac- tions with family and friends. Additional recreational opportunities can be anticipated at various venues – including the golf course, pool, beach, spa, or restaurants, not to mention the other attrac- tions on the island. All in all, this meeting promises to be a memorable experience.

Robert J. Spinner, M.D. ASPN 2007 Program Chair ASRM

The 23rd annual meeting of the ASRM this January 2007 promises to be one of our best yet. Our meeting venue returns us to beautiful Puerto Rico, this time to the incomparable Westin Rio Mar Beach Golf Resort and Spa. The meeting has a longstanding tradition of presenting cutting edge topics in microsurgery, panel discussions, and instructional courses applicable to the clinician as well as the researcher and this will continue. Structural changes to the instructional part of the meeting as well as marquis entertainment for the social portion of the meeting will mark the 2007 meeting as one not to be missed. This meeting will reflect suggestions the membership has made over the years to improve the ASRM meeting experience. One often noted complaint was not enough family and free time during the day to enjoy the venue and camaraderie outside the meeting. This complaint has been addressed by significantly restructuring the meeting. This year’s meeting will have significant free time each afternoon and plenty of activities to fill them with. Over 20 hours of free afternoon time have been programmed in. No reason to “skip” presentations or panels now. By one o’clock each afternoon, instructional activities will be curtailed and the free time begins! While we have chosen to make this prime time available for your enjoyment, our goal has been to maintain the high level of educational content and to avoid the reduction of CME available for the meeting. We have done this in a number of creative ways. While the number of presentations will remain constant, the time for presentation has been curtailed to 3 minutes. This has been partially offset by a necessary and requested increase in discussion time for each paper. Evening panels have been added. Self-study computer modules will also be available throughout the meeting for additional and valuable patient safety CME. Our speakers will continue to be top notch. Our president’s invited speaker will be Past President Ronald Zuker, MD. The Buncke lecturer will be one of the founders of our society, James Urbaniak, MD, who still practices microsurgery. Elisabeth Beahm, MD will preside over the 2007 Master’s Series which will present interactive video presentations from leaders in their fields. Panel discussions will feature facial transplantation, optimization of results in head and neck reconstruction, and new ideas in limb salvage. Other members have asked for more presentation and discussion of complications and their management. Others still would like a forum to present interesting and unique individual cases which would be of interest to us as microsurgeons. These single cases do not often warrant formal presentation on the podium. Both of these interests will be served in evening sessions. First, we will be presenting an award for the “Best Microsurgical Save” of the year. Submitted cases will be judged by an expert panel that will score cases based on degree of complication, originality of the microsurgical salvage, and the overall value of the case. The ultimate winner will be decided by the membership present. No formal attire is required and yes, the bar will be open. This should allow exposure to and discussion of complications in a fun and relaxing format. The second award will be for the “Best Microsurgical Case” of the year. We all do great cases throughout the year. Here’s your chance to share one with your colleagues and have bragging rights for a year by winning. Again panelists will critique the cases and the membership present will pick the winner. Solicitations for these awards will be sent throughout the year and can be submitted to me via the ASRM website. Perhaps most exciting is our announcement of Branford Marsalis as our featured entertainer. Monday night will feature a night of jazz with Branford Marsalis and his band. Branford has been very active with Harry Connick Jr. providing much needed relief for musicians affected by Hurricane Katrina through Habitat for Humanity. Our ASRM concert will benefit these efforts. This will be a night remembered for all time. Our Puerto Rican venue offers plenty of activities for our indulgence. Beautiful beaches, lush rain forests, daytrips to San Juan, golf, and poolside lounging are only a few of the attractions that await us.

Michael Zenn, MD, FACS ASRM 2007 Program Chair

14 GENERAL ANNOUNCEMENTS

MEETING SERVICE HOURS (subject to change) Stop by our meeting services desk in the Rio Mar Atrium for meeting information or assistance. Wednesday, January 10 7:00am - 6:00pm Thursday, January 11 7:00am - 4:00pm Friday, January 12 9:00am - 6:00pm Saturday, January 13 6:30am - 5:00pm Sunday, January 14 6:30am - 1:30pm; 6:30pm - 9:30pm Monday, January 15 6:30am - 1:00pm; 8:00pm - 10:00pm Tuesday, January 16 6:30am - 12:00pm

AAHS POSTER PRESENTATION VIEWING HOURS The AAHS Poster Presentations will be placed near the Rio Mar Foyer. Posters will be available for viewing Wednesday - Saturday. If you are a presenter, please have your posters set up prior to 12:00pm on Wednesday and taken down prior to 12:00pm on Saturday. The American Association for Hand Surgery will not be responsible for any poster that is not removed within the time allotted.

COMMERCIAL EXHIBITS The commercial exhibits will be located in Rio Mar Ballroom 5 and Foyer. A variety of commercial exhibits are featured at the meeting, enabling the attendees to learn about the technological advances pertaining to upper extremity surgery, and reconstructive microsurgery, and to meet key suppliers. Please refer to the Exhibit Listing in this book.

EXHIBIT HOURS Wednesday, January 10 6:30am to 11:00am AAHS ONLY exhibits open Thursday, January 11 7:00am to 1:30pm AAHS ONLY exhibits open Friday, January 12 6:30 am – 11:00am AAHS ONLY/ AAHS-ASRM-ASPN JOINT exhibits open Saturday, January 13 6:30am to 9:30am AAHS-ASRM-ASPN JOINT exhibits open 2:00pm to 4:00pm AAHS-ASRM-ASPN JOINT exhibits open Sunday, January 14 6:00am to 1:00pm AAHS-ASRM-ASPN JOINT and ASRM ONLY exhibits open Monday, January 15 6:00am to 12:30pm ASRM ONLY exhibits open Tuesday, January 16 6:00am to 10:30am ASRM ONLY exhibits open

SPEAKER READY ROOM HOURS The Speaker Ready Room will be located in San Cristobal on the Rio Mar Ballroom level.

Wednesday, January 10 6:30am - 2:00pm Thursday, January 11 6:30am - 4:00pm Friday, January 12 6:30am - 5:00pm Saturday, January 13 6:00am - 5:00pm Sunday, January 14 6:00am - 5:00pm Monday, January 15 6:00am - 1:00pm Tuesday, January 16 6:30am - 11:00am

DRESS CODE Casual attire. Ties are discouraged for any session or function.

MESSAGE BOARD/CYBER CAFE A message board will be set up near Meeting Services in Rio Mar Atrium. Please refer to the message board for meeting notices and general announcements. A Cyber Cafe will be located in the meeting area.

The AAHS/ASRM/ASPN would like to thank Kinetikos Medical Inc./KMI for their generous sponsorship of the Cyber Cafe

15 SOCIAL EVENTS Social events are offered to encourage networking and to enhance your meeting experience. Many of the events are included in your registration fee, and we encourage you to purchase tickets for your guests for all social events. We recommend that you purchase guest tickets in advance, as they will be available on a very limited basis at the meeting. Tickets will be collected at all events. AAHS Welcome Reception Wednesday, January 10: 6:00pm – 7:00pm Cost: One ticket included in AAHS registration. Additional tickets at $40 each. Tropical breezes and ocean views set the tone for a grand kick-off to a successful week ahead. Join us at Club Coqui as we enjoy the dramatic beauty of the Island’s outdoor scenery. AAHS Invited Speaker: Richard Kogan, MD Friday, January 12: 6:00pm - 7:30pm Cost: Complimentary to AAHS registrants and guests. “Music and : George Gershwin” George Gershwin (1898-1937) was one of the greatest composers in American history, writing memorable songs and concert pieces until his untimely death at age 38 of a brain tumor. Concert pianist and Dr. Richard Kogan will discuss Gershwin's life from a medical and psychiatric perspective and will perform Rhapsody in Blue and other examples of Gershwin's glorious music. Richard Kogan has a distinguished career both as a concert pianist and as a psychiatrist. He has been praised for his "eloquent, compelling and exquisite playing" by the New York Times and the Boston Globe wrote that "Kogan has somehow managed to excel at the world's two most demanding professions." He has gained international renown for his groundbreaking work on the connections between music and healing and on the influence of medical and psychiatric illnesses on the creative output of composers such as Mozart Beethoven, Schumann, Tchaikovsky, and Gershwin. His work forms the basis for the Yamaha DVD series entitled "Richard Kogan: Music and the Mind". Dr. Kogan is a graduate of the Juilliard School of Music and of Harvard College and Harvard . He completed his residency training at NYU. He currently has a private practice of psychiatry in New York City and is affiliated with the Weill - Cornell Medical School as Director of its Human Sexuality Program. AAHS Awards Dinner Dance Friday, January 12: 7:30pm – 8:00pm Reception; 8:00pm – 11:00pm Dinner and Dancing Cost: One ticket included in AAHS registration. Additional adult tickets are $175 each; tickets for children and young adults ages 5 – 18 @ $50 each. A picture perfect evening will unfold during this entertaining evening of dining and dancing to Puerto Rico’s hottest dance band, Kamaleon. They entertained us in 2005, and now they’re back by pop- ular demand to get the party started and keep it going all night long. Dress casual and prepare yourself for a night to remember. Festive beverages, hors d’ oeuvres, dinner wines and a multi-course gourmet dinner are all included in the adult ticket. An alternate menu and beverage selection will be served to children and young adults ages 5 – 18. 11th Annual Day at the Links Saturday, January 13: 12:30pm Shotgun Start Cost: $215 per player. Tickets are non-refundable. A shamble format tournament will take place on the Westin’s River Course, Greg Norman’s first Caribbean design. The 6,945 yard course rolls along the Mameyes River, framed by vistas of mountains and sea. Ideal for players of all skill levels, and typical of Norman’s courses, all 18 holes can rate the title of “signature.” Prizes will be awarded during our post event reception to 1st, 2nd and 3rd place teams, and individuals who win the longest drive, longest putt and closest to the pin competitions. Tournament registration is very limited this year, and may not be available for on-site registration. To be paired with specific players, requests must be submitted at the Registration Desk by noon on Friday, January 12. Tournament costs include shuttle service, box lunch, greens fees, cart, tournament coordination, prizes, range balls and an after golf reception. Pro-Line clubs are available to rent with advance reservation at $35 per set. ASRM International Reception Saturday, January 13: 6:00pm – 7:30pm Cost: One ticket included in ASRM registration. Additional tickets at $50 each. Join us as we kick off the ASRM Annual Meeting with our International Reception, highlighting the countries represented in the organization. Hear our colleagues reflect on what ASRM has meant to them and their organizations. Tropical hors d’oeuvres and cocktails will be served on the Ocean Terrace. The ASRM would like to thank ASSI for their generous sponsorship of this reception. ASPN Welcome Reception Saturday, January 13: 6:30pm – 8:00pm Cost: One ticket included in ASPN registration. Additional tickets at $50 each. Tropical breezes and ocean views will be the setting for this lively gathering at Club Coqui. Join us as we network and enjoy the dramatic beauty of the Island’s outdoor scenery. ASRM Branford Marsalis Jazz Charity Concert Event Monday, January 15: 8:30pm – 10:30pm Cost: One ticket included in ASRM registration. Additional tickets at $100 each. Experience a once-in-a-lifetime music event featuring one of the most popular jazz artists of our time. In a very limited, intimate setting at the Westin, Grammy Award winning saxophonist Branford Marsalis will perform for ASRM to benefit Habitat for Humanity’s Musicians’ Village. The devastation caused by Hurricane Katrina forced many of New Orleans’ musicians to flee the city. The Musicians' Village, an effort co-chaired by Marsalis, has endeavored to build 81 Habitat-constructed homes in the Upper Ninth Ward for displaced New Orleans musicians. Learn more about this accomplished artist and the project at www.branfordmarsalis.com. This ticket is for a charitable event sponsored by the ASRM a 501(c) 3 not for profit organization. Net proceeds from this event will be contributed to The New Orleans Habitat Musicians’ Village. The ASRM would like to thank Smith and Nephew for their generous co-sponsorship of this event. OPTIONAL TOURS AND ACTIVITIES The Westin offers its guests a wide variety of organized Island tours and daily youth and adult activities that take place at The Westin. When you arrive at The Westin, you’ll have an opportunity to visit with the concierge to plan the activities of your choice. Some of the fee-based and complimentary activities available daily: Deep Sea Fishing, Power Walks, Wave Runners, Catamaran Sailing, Hair Braiding, Family Pool and Lawn Games, Bingo, Yoga Classes, Iguana Feeding, Volleyball, Horseback Riding, Sunset Sail, Basketball, Dive Trip, Aqua Aerobics, Latin Dance, Iguana Kids Club, Casino, Tennis, Golf, Shopping, and much more. If you prefer to join in with fellow association members, we’ve made special arrangements for a few private tours that can be reserved in advance. On-site ticket purchases will be limited, and some tours may be unavailable. If tour ticket minimum sales are not met, some tours may be cancelled. In these cases, all advance reservation payments will be fully refunded. El Yunque Rain Forest Tour Offered: Saturday, January 13, 1:00pm – 5:00pm; Sunday and Monday, 14th and 15th, 1:30 pm – 5:30 pm. Cost: $44 per adult; $40 per child ages 6 – 12 years of age The most visited natural sight on the island, El Yunque is the only tropical rain forest in the U.S. National Forest System. Spanning 28,000 acres and reaching an elevation of 3,624 feet, the area receives over 100 million gallons of rainfall each year. Explore leaf-canopied paths on this guided walking tour and learn about the endangered Puerto Rican parrot or the famous coquí frogs as you walk amongst over 240 different species of trees, ferns and flowers. You’ll also have the opportunity to visit the Yohaku observation tower and see a spectacular view of St. Thomas. Wear your swimsuit under your clothing and enjoy a refreshing swim under a stunning waterfall. Transportation, guide, park admission, bottled water and gratuity included. Some incline and decline walking is required. Old San Juan Historical Walking Tour and Shopping Offered: Saturday, January 13, 12:00 pm – 5:00pm; Sunday, 14th, 1:00 p.m. – 6:00 p.m.; Monday, 15th 1:30 pm – 6:30 pm. Cost: $55.50 adult; $50 per child ages 3 – 6 years of age Forty-Five minutes from the Westin, find cobblestone streets, colorful buildings, centuries-old fortresses, street merchants and charming shops, all bathed by a tropical breeze. Meet the legendary Old San Juan. This brief guided walking tour is followed by time to explore the quaint shops and eateries of Old San Juan on your own. Transportation, guide, bottled water and gratuity included. Bioluminescent Bay Evening Kayak Tour Offered: Saturday, January 13, 7:45 pm – 11 pm Cost: $87 adult; $78 per child ages 6 – 12 years of age For something truly magical, the world-renowned bioluminescence of the Laguna Grande in Fajardo cannot be missed. Spend twilight kayaking above what is considered one of the brightest displays of mysterious blue-green light emitted by dinoflagellates in the world. This relaxing kayak tour can be enjoyed by adults and children over age 6 who are willing and able to paddle. Transportation, guide, kayak gear, bottled water and gratuity included. This tour has limited availability. ASRM “Pamper Package” Guest Program Sunday, January 14, 7:00 pm – 9:00 pm Cost: One ticket included in ASRM’s Spouse/Guest Fee. A la carte tickets are $25 for adults, and $15 for children age 12 – 18. We’ve designed this special evening event exclusively for our ASRM guest attendees to coincide with the Scientific Meeting’s evening programming schedule. Join us for an inside look at health and beauty through the eyes of a professional esthetician. The staff of the resort’s famed Mandara Spa is our host for this up close and personal gathering where we’ll learn about the tricks of the trade for restoring our youthful, glowing skin. The facial demonstration will be followed by an opportunity to sample luxury products from the lines of La THERAPIE and Elemis. Festive beverages and sweet treats are all part of our Pamper Package. Participation is limited; sign up early to be guaranteed a seat. Please, no children under age 12.

16 AMERICAN SOCIETY OF ASSI Booth: 20 PLASTIC SURGEONS Proud sponsor of the ASRM International Reception Marie Bonazinga Booth: 23 300 Shames Drive, Westbury, NY 11590 Emily Matzelle phone- 516-333-2570 fax-516-997-4948 American Society of Plastic Surgeons email- [email protected] 444 East Algonquian Rd. website- www.accuratesurgical.com Arlington Heights, IL 60005 ASSI will feature the Engler Breast Retractor, the Stanger C Brest Retractors and the new Phone- 847-228-9900 fax- 847-981-5482 Lalonde Breast Sizers, the Lalonde Percutaneous Bone Clamp with K-wire guide, Face Lift email- [email protected] Retractors, Campbell Lip Awl, Matarasso Lipo Roller and SuperCut Face Lift Scissors, ASSI’s website- www.plasticsurgery.org Bipolar Scissors, Micro Monopolar Forceps, the Surex Sural Nerve Extractor and Nerve Holding/Cutting Forceps. ASSI’s Hand Crafted Microsurgical Instruments and Clinical The American Society of Plastic Surgeons is the largest organization of board-certified Microvascular Clamps. plastic surgeons in the world. With 6,000 members, the society is recognized as a leading authority and information source on cosmetic and reconstructive . The soci- ety represents certified by The American Board of Plastic Surgery or The Royal BIOMET TRAUMA College of Physicians and Surgeons of Canada. Booth: 1 Charlie Eaton ANATOMY GIFTS REGISTRY 100 Interpace Pkwy., Parsippany, NJ 7054 phone- 973-299-9300 fax-973-299-0391 Booth: 33 email- [email protected] Brenda Bardsley website- ebimed.com 7522 Connelley Drive, Suite P Biomet-New Jersey (formerly EBI, L.P.) develops and markets a full range of internal and Hanover, MD 21076 external orthopedic devices used in fracture fixation of the upper extremity. This includes phone- 410-553-0525 fax-410-553-0502 the OptiLock Distal Radius Plating System, Uniflex Humeral Nail and a variety of distal radius fixators. email- [email protected] website- www.anatomicgift.com Anatomy Gifts Registry is a non-profit Donor Registry specializing in procurement, preser- BME vation and distribution of human tissue on an individualized investigator basis. AGR is licensed by the State of New York as a Non-Transplant Anatomic Bank. For information Booth: 11 on specimen availability or application please call (410) 553-0525 or e-mail Lisa May [email protected]. Marketing Specialist 14785 Omicron Dr., #205, San Antonio, TX 78245 Phone- 800-880-6528 fax- 210-677-0355 (FORMERLY SURGICAL SPECIALTIES CORPORATION) ANGIOTECH email- [email protected] Booth: 34 website- www.bme-tx.com Erika Fry 100 Dennis Drive, Reading, PA 19606 COOK MEDICAL Phone- 610-404-1000 fax- 610-404-2061 e-mail- [email protected] Booth: 19 website- www.angiotech.com / www.surgicalspecialties.com Rachel Barnhill Angiotech, formerly Surgical Specialties Corporation, features a wide rage of Sharpoint® 750 Daniels Way, Bloomington, IN 47404 micro-sutures and microsurgical knives – designed to meet the specific demands of the phone- 812-339-2235 fax-812-339-3704 micro-surgeon. They also offer micro-training materials including: manuals, non-sterile email- [email protected] sutures and PracticeRat™. Stop by our booth and take a macro view of your full line micro website- www.cookmedical.com company. Cook® presents two unique products: The Cook-Swartz implantable Doppler Blood Flow probe with new DP-M250 Monitor offering the latest technology for continuous confir- mation of vascular patency. Surgisis®, an absorbable porcine small intestinal submucosa APTIS biomaterial that provides a scaffold for host tissue remodeling, creating a natural, cost- Booth: 14 effective alternative to surgical repair. Barbara Chesher DVO 5 River Hill Rd., Louisville, KY 40207 phone- 502-561-4240 fax-502-585-0009 Booth: 3 email- [email protected] Rachel Bushong website- www.anatomicgift.com 720 East Winona Ave., Warsaw, IN 46580 APTIS MEDICAL specializes in taking current concepts to the next level. With the success phone- 877-777-9382 fax-574-258-1542 of the Scheker DRUJ prosthesis, Aptis has provided a product that totally replaces the email- [email protected] DRUJ, prevents subluxation and allows the bearing of weight. Other new and innovated website- www.dvosolutions.com designs for joint replacement are soon to follow DVO Solutions creates unique implant and instrumentation solutions for the upper extremities market. DVO will be showcasing our new Volar Plate System incorporating lag screw and CoverLoc ™ Technology. We will also be displaying our MIfx™ System that con- ASCENSION ORTHOPEDICS tains our Dorsal IM Plate and Intrafocal Pin Plate. Booth: 9 Patsy Peterson HOLOGIC, INC. 8700 Cameron Rd., #100 Booth: 10 Austin, TX 78723 Nicole Athanas phone- 512-836-5001 fax-512-836-5145 35 Cosby Drive, Bedford, MA 1730 email- [email protected] phone- 781-999-7342 fax-781-280-0668 website- www.ascensionortho.com email- [email protected] Ascension Orthopedics is dedicated to the research, development, manufacture and distri- website- www.hologic.com bution of revolutionary orthopedic devices for the hand, upper extremity, and foot. The Fluoroscan® mini C-arm X-ray systems from Hologic are designed for orthopedic surgeons company founders are pioneers in the material science to combat the debilitating effects performing minimally invasive surgical procedures of the extremities, as well as for low- of arthritis. dose, in-office imaging.

17 HAND SURGERY ENDOWMENT MICROSURGERY INSTRUMENTS, INC Booth: TABLE TOP Booth: 16 Laura Downes Leeper, CAE Nancy Kang 20. N. Michigan Ave., Suite 700 7211 Regency Sq. Blvd #223, Houston, TX 77036 Chicago, IL 60602 Phone- 713-664-4707 fax- 713-664-8873 Phone- 312-236-3307 e-mail- [email protected] email- [email protected] Microsurgery Instruments, Inc. is one of the leading suppliers for surgical loupes and instruments in the United States and many other countries. We are well known in a large The Hand Surgery Endowment supports education and research to improve patient care number of surgical fields including: Orthopedics, Plastic Surgery, Hand Surgery, ENT, and safety of the hand and upper extremities. The Endowment funds scholarships and , , Neurosurgery, and in many other more fields. awards; public awareness, research projects and AAHS strategic initiatives that promote optimal hand and upper extremity health and safety.

INTEGRA NDI Booth: 29 Proud sponsor of the ASPN Invited Speakers Booth: 18 Jon Trout Jim Gabriel 311 Enterprise Dr., Plainsboro, NJ 8536 One Chagrin Highlands, 2000 Auburn Dr., Ste 320, Cleveland, OH 44122 Phone- 609-275-0500 fax- 609-799-3297 Phone- 216-378-9106 fax- 216-378-9116 e-mail- [email protected] e-mail- [email protected] website- www.integra-ls.com website- www.ndimedical.com Integra develops, manufactures, and markets medical devices for neuro-trauma and neu- NDI Medical is a neurostimulation medical device company. The Checkpoint stimulator rosurgery, plastic and reconstructive surgery and general surgery. Integra’s peripheral is a surgical tool that provides surgeons with a reliable method of applying electrical stim- nerve surgery products include NeuraGen™ for completely severed nerves and ulation to exposed motor nerves and muscle tissue to locate and identify nerves. The NeuraWrap™ for compressed, scarred or partially injured nerves. variable parameters provide reliable feedback while testing nerve and muscle excitability.

KINETIKOS MEDICAL INC./KMI Booth: 28 NEXA ORTHOPEDICS Danielle Macrorie 6005 Hidden Valley Rd., Suite 180 Booth: 13 Carlsbad, CA 92011 Proud sponsor of the Cyber Cafe Patricia Dorgan Phone- 760-448-1700 ext.1422 fax- 760-448-1739 Marketing Services Manager e-mail- [email protected] 11035 Roselle Street, San Diego, CA 92121 Phone- 800-835-8480 fax- 858-866-0661 e-mail- [email protected] website- www.nexaortho.com MED LINK USA Nexa Orthopedics, the technology leader in products for reconstructive surgery of the Booth: 30 extremities, is introducing its first products in its new pyrocarbon implant line. Please stop by the booth to see our new pyrocarbon CMI (basal thumb) and PI 2 (trapezium), and Tod Kellen Radial Head systems. PO BOX 42483, Des Moines, IA 50323 Phone- 800-762-7921 fax- 800-329-5990 e-mail- [email protected] website- www.medlinkusa.com SMALL BONE INNOVATIONS MEDARTIS Booth: 5 Carolyn Desautels Booth: 6 Global Meetings Manager Erin Graybill 1711 S. Pennsylvania Ave., Morrisville, PA 19067 127 W. Street Road, Suite 203, Kennett Square, PA 19348 Phone- 215-428-1791 fax- 215-428-1805 Phone- 610-961-6101 fax- 610-961-6108 e-mail- [email protected] e-mail- [email protected] website- www.totalsmallbone.com website- www.medartis.com Small Bone Innovations, Inc. (“SBI”) is focused on the needs of the small bone & joint Medartis is committed to providing surgeons and operating theatre personnel in ortho- surgeon resulting in surgeon designed and clinically proven products. SBI is continual- pedic and cranio-maxillofacial surgery with innovative implants, instruments and servic- ly expanding its portfolio to become the worldwide leader in the design, development, manufacture, and marketing of upper and lower extremity medical devices. es that represent advances in osteosynthesis and thus patients’ quality of life. To help it do justice to this ambitious aim, Medartis relies heavily on close collaboration with sur- geons, scientists, universities and hospitals

MICRINS SURGICAL SMITH AND NEPHEW Booth: 31 Booth: 15 Bern Teitz Jennifer Waddell 28438 Ballard Dr., Lake Forest, IL 60048 Educational Conference Coordinator Proud co-sponsor of the ASRM concert event. Phone- 847-549-1410 fax- 847-549-1510 11775 Starkey Rd., Largo, FL 33773 e-mail- [email protected] With an emphasis on customer-driven technology and innovation, our goal at Smith & Micrins Features well over 3500 different instruments and accessories for Aesthetic, Hand, Nephew is to continue anticipating the future of excisional debridement. VersaJet™ is a Micro and Reconstructive Surgery. Our product offering includes: The Micrins® brand of specialized fluid jet instrument that enables surgeons to easily grasp, cut and remove Hand Held Surgical Instruments, Razor-Edge Scissors, and Genuine Stille Surgical damaged tissue and contaminants from surgical, traumatic and chronic wounds and Instruments. The Micrins booth is conveniently located in the center of the exhibit hall. burns in a precise and safe manner.

18 SPRINGER THE GUATEMALA HEALING Booth: TABLE TOP HANDS FOUNDATION Acasia Dalmau Booth: 12 233 Spring St., New York, NY 10013 Phone- 212-460-1600 fax- 201-272-1832 Mona Lipson e-mail- [email protected] 290 6th Ave., Brooklyn, NY 11215 website- www.springer.com Phone- 718-768-5927 e-mail- [email protected] Stop by and browse Springer’s selection of Hand Surgery publications, and pick up your free sample copy of HAND, the new official journal of the American Association for Hand Surgery. website- www.guatemalahands.org GHHF is a nonprofit organization dedicated to improving the quality and availability of hand care in Guatemala through education, surgery, and . Specializing in the treatment of congenital and hand injuries, we aim to reach the Guatemalan population through medical missions led by a volunteer team of specialized and skilled surgeons, therapists, and dedicated volunteers. STRYKER ORTHOPAEDICS Booth: 7 & 8 FOR AAHS AND 21 FOR JOINT Peter Valente 325 Corporate Dr., Mahwah, NJ 7430 Proud sponsor of the Bottled Water Phone- 201-831-5276 fax- 201-831-6453 and AAHS President’s Dinner THIEME PUBLISHERS e-mail- [email protected] Booth: 17 Stryker range of Upper Extremities and Hand Products offers a full range of options from Intramedullary nails, external fixation devices, screws, pins, plates and new orthobiolog- Ross Lumpkin or Daniel Schiff ic solutions for fracture treatment. Industry recognized product lines such as T2®, 333 Seventh Ave., New York, NY 10001 Hoffmann™, Asnis™ III, Variax and Profyle Hand Products. Phone- 212-584-4706 fax- 212-947-1112 e-mail- [email protected] website- www.thieme.com Established in 1886, Thieme is a major international publisher with offices in New York, Stuttgart, and Singapore. The company publishes the Journal of Reconstructive Microsurgery (Editor-in-Chief, Berish Strauch, MD), and recently released the new edition of the best selling book, Atlas of Microvasular Surgery by Berish Strauch and Han-Liang Yu. SYNOVIS Booth: 24 & 25 Britt Maganzini Proud sponsor of the ASPN website and ASRM “Best Microsurgical Awards” 739 Industral Lane, Birmingham, AL 35211 Phone- 205-941-0111 e-mail- [email protected] TRI MED, INC. Synovis MCA, “the microsurgeon’s most trusted resource,” provides innovative advance- ments and technologies for microsurgeons. The COUPLER and GEM MicroClips are pre- cise instruments that help save valuable OR time and enable microsurgeons to perform Booth: 4 highly effective anastomotic surgical procedures faster, easier and more dependably than Jim Fassett traditional suture anastomosis. The GEM Neurotube® is an absorbable woven polygly- 869 Main Street, Walpale, MA 2081 colic acid mesh tube designed for peripheral nerve repair and reconstruction. Phone- 508-668-0988 fax- 508-668-0212 Introducing Veritas® Collagen Matrix, an advanced technology in soft tissue repair, saves time, is biocompatible and remodelable, has exceptional handling and comes in a vari- e-mail- [email protected] ety of sizes. Biover Microvascular Clamps are disposable and produce a consistent meas- website- www.trimedortho.com ured pressure. S&T® microsurgical instruments are crafted from premium materials and built from a solid foundation of research, expert cooperation and engineering. The Varioscope® is the world’s smallest head-mounted surgical microscope.

SYNTHES VIOPITIX, INC Booth: 2 Booth: 26 Lisa Kauffman Denise Yarmlak 1301 Goshen Parkway, West Chester, PA 19380 44061-B Old Warm Springs Blvd., Fremont, CA 94538 Phone- 610-719-6873 fax- 610-719-6533 Phone- 510-226-5806 x 217 e-mail- [email protected] e-mail- [email protected] website- www.synthes.com Synthes CMF is the sole authorized North American manufacturer and distributor of AO The ViOptix™ Tissue Oximeter is a proprietary breakthrough product and technology that ASIF instruments and implants for internal fixation of craniomaxillofacial and mandibu- enables non-invasive, direct, real-time measurement of local tissue oxygen saturation. lar trauma and reconstruction. Our product offering includes distraction osteogenesis The ViOptix™ Tissue Oximeter is used in reconstructive flap and digit replanta- devices, resorbable plating, and bone graft substitutes. Synthes CMF also supports North tion to assess and monitor tissue viability post-operatively, thereby improving medical American AO ASIF Continuing Education courses. outcomes and decreasing cost.

19 AAHS CONTINUING

AAHS MEETING OBJECTIVES: 1. To present clinical and basic science studies on a variety of hand and upper extremity problems. 2. To integrate principles of hand therapy with surgical management of hand and upper extremity problems. 3. To review principles of managing common hand and upper extremity problems. 4. To enhance the intellectual discourses of the annual meeting through an integrated program with the related surgical societies of the AAHS, ASRM and the ASPN. 5. To implement bioskills courses and enhance management of fractures and arthritis. 6. To present hand therapy issues related to the evidence-based intervention for a variety of hand problems and fractures. 7. To encourage the exchange of knowledge and expertise of the various specialties involved with hand surgery.

METHODS TO ACHIEVE THESE OBJECTIVES WILL BE: 1. Original research will be presented as papers in an open session that will encourage audience participation. 2. Recognized experts will present instructional courses and panels on hand and upper extremity problems. 3. Hand therapy principles will be reviewed on a special focused day and throughout the meeting. 4. A combined meeting with outstanding papers contributed by the AAHS, ASRM and ASPN with a focus on nerve , Brachial Plexus injury, and war injuries. 5. Bioskills courses will be presented on operative procedures related to fractures and arthritis using cadaver dissections to illustrate surgical techniques.

ACCREDITATION/CME The American Society of Plastic Surgeons® (ASPS®) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Plastic Surgery Educational Foundation(r) (PSEF®) is the clinical education arm of the ASPS. The PSEF designates this educational activity for Category I credit towards the American Medical Association Physician’s Recognition Award as follows (Credit hours subject to change):

AAHS ANNUAL MEETING January 10-13, 2007 13.75 hours

COMPREHENSIVE HAND SURGERY REVIEW COURSE January 12, 2007 5.25 hours

AAHS/ASRM/ASPN COMBINED DAY January 13, 2007 4.0 hours

Additional CME hours are available for Instructional/Bioskills Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows:

Course # CME Bioskills Workshops BW1 - BW6 2.0 hours each Instructional Courses 102 - 107 1.0 hour each Instructional Courses 108 - 113 1.0 hour each Instructional Courses 115 - 120 1.0 hour each Credit hours are subject to program changes.

COPYRIGHT All of the proceedings of the annual meeting, including the presentations of scientific papers, are intended solely for the benefit of the membership of the American Association for Hand Surgery. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or presen- tation is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker or to theamerican Association for Hand Surgery. Any sound reproduction, transcript, or other use of material presented at the meeting without the per- mission of the speaker or the American Association for Hand Surgery is prohibited to the full extent of common law copyright in such material.

THE USE OF CAMERAS OR PHOTOGRAPHIC EQUIPMENT IS NOT PERMITTED DURING THE PRESENTATION OF SCIENTIFIC PAPERS.

20 ASPN CONTINUING MEDICAL EDUCATION

ASPN MEETING OBJECTIVES: 1. To present and discuss experimental techniques in nerve research. 2. To provide exposure to emerging technologies in the management of nerve and extremity injuries. 3. To understand electrodiagnostic evaluation of acute and chronic nerve injuries. 4. To present and discuss the management of nerve injury and nerve tumors. 5. To present and discuss evolving management of nerve injury causing pain. 6. To present and discuss the physiology of the neuromuscular junction and muscle reinnervation.

METHODS TO ACHIEVE THESE OBJECTIVES WILL BE: 1. Scientific presentations on current and recent advances in research on nerve injury and repair. 2. Seminars from invited experts on specialized topics related to reinnervation, reconstruction and nerve tumors. 3. Invited lectures from clinical scientists and researchers in nerve biology, pathophysiology and injury.

ACCREDITATION/CME The American Society of Plastic Surgeons® (ASPS®) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Plastic Surgery Educational Foundation® (PSEF®) is the clinical education arm of the ASPS. The PSEF designates this educational activity for Category I credit towards the American Medical Association Physician’s Recognition Award as follows (Credit hours subject to change):

AAHS/ASRM/ASPN COMBINED DAY January 13, 2007 4.0 hours

ASPN ANNUAL MEETING January 13 - 14, 2007 13.0 hours

Additional CME hours are available for Instructional Courses on an hour-for-hour basis, awarded solely based on registration lists, as follows:

COURSE # CME Instructional Courses 201 - 205 1.00 hour each Credit hours are subject to program changes.

COPYRIGHT All of the proceedings of the annual meeting, including the presentations of scientific papers, are intended solely for the benefit of the membership of the American Society for Peripheral Nerve. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any state- ment or presentation made at the meeting is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker or to the American Society for Peripheral Nerve. Any sound reproduction, transcript, or other use of mate- rial presented at the meeting without the permission of the speaker or the American Society for Peripheral Nerve is prohibited to the full extent of common law copyright in such material.

DISCLAIMER The content of this program is presented solely for educational purposes and is intended for use by medical practitioners in the peripheral nerve specialty. This material is intended to express the opinions, techniques or approaches of the authors and presenters, which may be beneficial and/or of interest to other prac- titioners. Sponsorship of this program is not to be construed, in any fashion, as an endorsement of the materials presented. The view expressed and the subject material presented in the course of any activities sponsored by the American Society for Peripheral Nerve including lectures, seminars, instructional courses, or otherwise, represent the personal views of the individual participants and do not represent the opinion of the American Society for Peripheral Nerve. The Society assumes no responsibilities for such views or materials, and hereby expressly disclaims any and all warranties, expressed or implied, for the content of any Society sponsored presentations. Further, the Society hereby acknowledges that while its broad purpose is to promote the devel- opment and exchange of knowledge pertaining to peripheral nerve regeneration; it does so only in the contest of a private forum without making any represen- tations to the public whatsoever. Accordingly, the Society declares that its primary purpose is to benefit only its physician members, and responsibility of the Society for acts or omissions of Society members dealing with the public is hereby expressly disclaimed.

THE USE OF CAMERAS OR PHOTOGRAPHIC EQUIPMENT IS NOT PERMITTED DURING THE PRESENTATION OF SCIENTIFIC PAPERS.

21 ASRM CONTINUING MEDICAL EDUCATION ASRM MEETING OBJECTIVES: 1. To provide the membership with an update on the state of the art techniques for microsurgical and complex reconstruction via peer reviewed scientific presentations on clinical and basic science research. 2. To provide scientific and academic interaction and foster collaboration amongst the American Association for Hand Surgery, the American Society for Peripheral Nerve and the American Society for Reconstructive Microsurgery. 3. To provide education opportunities for practicing surgeons, residents and fellows. 4. To provide the attendees a focused update on specific topics in the form of expert panel presentations. 5. To encourage participation by colleagues from around the world. METHODS TO ACHIEVE THESE OBJECTIVES WILL BE: 1. Free papers to be presented in the open forum that allows audience discussion. 2. National and international experts will provide different instructional courses on each day of the meeting. 3. Panels by national and international experts will discuss conventional, new and controversial aspects of microsurgery and complex reconstruction. 4. Patient Safety CME will be available by meeting participation and specialized computer modules available throughout the program. 5. Specific mailing and invitations will increase participation of colleagues from around the world. 6. Daily social events will provide interaction amongst colleagues, societies, and trainees. 7. A conjoint scientific session including panels, instructional courses will be maintained on Saturday with the AAHS and on Sunday with the ASPN. ACCREDITATION/CME The American Society of Plastic Surgeons® (ASPS®) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Plastic Surgery Educational Foundation® (PSEF®) is the clinical education arm of the ASPS. The PSEF designates this educational activity for Category I credit towards the American Medical Association Physician’s Recognition Award as follows (Credit hours subject to change): AAHS/ASRM/ASPN Combined Day January 13, 2007 4.0 hours ASRM Master Series in Microsurgery January 13, 2007 3.5 hours ASRM Annual Meeting January 14 - 16, 2007 16.5 hours

Additional CME hours are available for Instructional Courses and Patients Safety Computerized Presentations on an hour-for-hour basis, awarded solely based on registration lists, as follows: Course # CME Patients Safety Computerized Presentations 1.00 hour each Instructional Courses 301 - 307 1.00 hour each Instructional Coruses 308 - 314 1.00 hour each Instructional Courses 315 - 321 1.00 hour each Credit hours are subject to program changes. COPYRIGHT All of the proceedings of the annual meeting, including the presentations of scientific papers, are intended solely for the benefit of the membership of the American Society for Reconstructive Microsurgery. No statement or presentation made at the meeting is to be regarded as dedicated to the public domain. Any statement or presentation is to be regarded as limited publication only and all property rights in the material presented, including common law copyright, are expressly reserved to the speaker or to the American Society for Reconstructive Microsurgery. Any sound reproduction, transcript, or other use of material presented at the meeting with- out the permission of the speaker or the American Society for Reconstructive Microsurgery is prohibited to the full extent of common law copyright in such material. DISCLAIMER The views expressed and the subject material presented in the course of any activities sponsored by the American Society for Reconstructive Microsurgery includ- ing lectures, seminars, instructional courses, or otherwise, represent the personal views of the individual participants and do not represent the opinion of the American Society for Reconstructive Microsurgery. The Society assumes no responsibility for such views or materials, or implied, for the content of any Society sponsored presentations. Further, the Society hereby acknowledges that while its broad purpose is to promote the development and exchange of knowledge per- taining to the practice of microsurgery; it does so only in the context of a private forum without making any representation to the public whatsoever. Accordingly, the Society declares that its primary purpose is to benefit only its members, and responsibility of the Society for acts or omissions of Society members dealing with the public is hereby expressly disclaimed.

THE USE OF CAMERAS OR PHOTOGRAPHIC EQUIPMENT IS NOT PERMITTED DURING THE PRESENTATION OF SCIENTIFIC PAPERS.

22 American Association for Hand Surgery American Society for Reconstructive Microsurgery American Society for Peripheral Nerve 2007 Annual Meeting PRESENTERS’ DISCLOSURES

THE FOLLOWING ANNUAL MEETING PRESENTERS HAVE INDICATED THE FOLLOWING DISCLOSURES: Chris Attinger, MD, serves on the speakers’ bureau for Integra, Johnson & Johnson and Smith & Nephew. Robert D. Beckenbaugh, MD, has financial ties to Ascension Orthopedics. Allan Belzberg, MD, receives research funding from DOD and UCB. Charles Butler, MD William P. Cooney, MD has a know-how license with Small Bone Innovation. Scott G. Edwards, MD serves as a consultant for Medartis. Alan Freeland, MD, receives departmental and institutional support from AONA and royalties from Elsevier Publishing Company. William Geissler, MD, serves as a consultant to Acumed Gerald H. Jordan, MD, receives royalties from C & S Surgical. Along with that he is a board member for Engineers and Doctors and a lecturer for CIEF. He also serves as a consultant for American Medical Systems and is involved in clinical trials with the following companies: Engineers & Doctors, Mentor, American Medical Systems, Auxilium. Don Lalonde, MD, serves as a consultant for ASSI. W. P. Andrew Lee, MD, serves as a consultant for Biomimetic Pharmaceutical Inc. Luis R. Scheker, MD, owns a patent for a total distal radioulnar joint prosthesis. Robert J. Spinner, MD, receives royalties for work licensed through Mayo Clinic to a privately held company for contributions related to the use of nerve signal modulation to treat central, autonomic, and peripheral nervous system disorders, including pain. Mayo Clinic receives royalties and owns equity in this company. The company does not currently license or manufacture any drug or device in the medical field. John Taras, MD has received an honorarium from Integra. The following presenters will include a discussion of an “off-label” or other non-FDA-approved, investigational use of medical devices or pharmaceutical products during their presentation. They will disclose that the product is not labeled for use under discussion or that the product is still investigational. Nicholas Vedder, MD THE FOLLOWING PRESENTERS DID NOT SUBMIT DISCLOSURE DOCUMENTS: Prof. Xavier Navarro Acebes, MD, PhD Richard Berger, MD, PhD Ronald Palmer, MD Richard E. Brown, MD William C. Pederson, MD Bernard Chang, MD Matthew Putnam, MD David T. W. Chiu, MD Mark Rekant, MD Peter G. Cordeiro, MD David Ring, MD Zoe Dailliana, MD Teri Skirven, OTR/L, CHT Coleen Gately, MS, PT, DPT Joseph Slade, III, MD Ralph Gilbert, MD Hans-Ulrich Steinau, MD Tessa Gordon, PhD Rebecca von der Heyde, MS, OTR, CHT Michael R. Hausman, MD Fu-Chan Wei, MD, FACS Joy MacDermid, PhD, PT Andrew Weiland, MD Wyndell H. Merritt, MD Aviva Wolff, OTR/L, CHT Peter C. Neligan, MD Jianguang Xu, MD, PhD Jorge L. Orbay, MD Ron Yu, MD

The remainder of the annual meeting presenters have indicated in writing that they have nothing to disclose and/or will not discuss any “off-label” or other non-FDA-approved, investigation use of a medical device or pharmaceutical product.

23 FUTURE ANNUAL MEETING LOCATIONS AAHS ASPN ASRM 2008 ANNUAL MEETING 2008 ANNUAL MEETING 2008 ANNUAL MEETING January 9 - 12, 2008 January 12 - 13, 2008 January 12 - 15, 2008 The Hyatt Century Plaza Hotel and Spa The Hyatt Century Plaza Hotel and Spa The Hyatt Century Plaza Hotel and Spa Beverly Hills, California Beverly Hills, California Beverly Hills, California The 2008 Annual Meetings with have an added touch of contemporary glamour and style at the Hyatt Regency Century Plaza. Perfectly situated in the fashionable Beverly Hills area, this elegant hotel offers easy access to all the sights and attractions that make Los Angeles great. Newly renovated guest rooms, world-class spa and fitness center and scintillating dining makes this luxury hotel feel more like a resort. Bring the whole family and enjoy a winter retreat that offers something for everyone.

2009 ANNUAL MEETING 2009 ANNUAL MEETING 2009 ANNUAL MEETING January 7 - 10, 2009 January 10 - 11, 2009 January 10 - 13, 2009 Grand Wailea Resort Hotel and Spa Grand Wailea Resort Hotel and Spa Grand Wailea Resort Hotel and Spa Maui, Hawaii Maui, Hawaii Maui, Hawaii

2010 ANNUAL MEETING 2010 ANNUAL MEETING 2010 ANNUAL MEETING January 6 - 9, 2010 January 9 - 10, 2010 January 9 - 12, 2010 Boca Raton Resort and Club Boca Raton Resort and Club Boca Raton Resort and Club Boca Raton, Florida Boca Raton, Florida Boca Raton, Florida

24 AAHS DAY-AT-A-GLANCE Wednesday, January10, 2007

6:30am - 2:00pm Speaker Ready Room San Cristobal

6:30am - 7:30am Continental Breakfast with Exhibitors Rio Mar Foyer & Ocean Terrace

7:00am - 6:00pm Meeting Services and Cyber Cafe Rio Mar Atrium

7:30am - 1:30pm Specialty Day Program: Rapid Recovery - The Fast Track Rio Mar 6

10:45am - 11:00am Break with Exhibitors Rio Mary Foyer

1:00pm - 5:00pm La Federacion del Mano Inaugural Meeting Rio Mar 7

3:30pm - 5:30pm Bioskills Workshops

BW-1 Current Techniques for PyroCarbon MCP/PIP/CMC Rio Mar 1 Arthroplasty BW-2 Current Techniques for DRUJ Disorder Rio Mar 2 BW-3 Treatment of Distal Radius Fractures Rio Mar 8 BW-4 Open & Arthroscopic Treatment of Thumb CMC Arthritis Rio Mar 9 BW-5 Minimal Resection Total Wrist Arthroplasty; Rio Mar 10 Surgical Technique & Case Review BW-6 Hand & Upper Extremity Solutions Sea Gull

6:00pm - 7:00pm AAHS Welcome Reception Club Coqui & Poolside Terrace

25 11:20am – 11:30am Surgical Treatment – When to fix, When to wait AAHS Andrew Weiland, MD Wednesday, January 10, 2007 11:30am – 11:40am Protective Gear – Rules, Regulations, Requirements Michelle Carlson, MD 6:30am – 7:30pm Continental Breakfast with Exhibitors 11:40am – 11:50am Methods of Protection – Splints, Padding 7:30am – 1:30pm Specialty Day Program: Rapid Recovery Coleen Gately, MS, PT, DPT The Fast Track 11:50am – 12:00pm Casting Techniques for Sports Activities Experts will present the latest techniques to treat and Ronald Palmer, MD rehabilitate your patient for fastest recovery follow- 12:00pm – 12:10pm The Injured Golfer Aviva Wolff, OTR/L, CHT ing hand and wrist injuries. Hear how to get your athlete, work injured patient, or family friend back to Case Presentations: When Rapid is Not So Rapid work and play as quick as possible using new 12:10pm – 12:20pm My Experience with Firefighters surgical and rehabilitation methods. Relative risks Joy Macdermid, PT, PhD, CHT compared to more “traditional” methods will also be 12:20pm – 12:30pm My Experience with the Not So Healthy Worker discussed. And, don’t forget to join us for a little Susan Michlovitz, PT, PhD, CHT side show of golf – test your skills and win a prize. 12:30pm – 12:40pm Rapid Recovery and Nerve Injury, an Oxymoron? Brian Adams, MD, Program Co-Chair Christine Novak, MS,PT, PhD(c) Aviva Wolff, OTR/L, CHT, Program Co-Chair 12:40pm – 1:00pm Panel/Discussion 7:30am – 7:35am President’s Welcome Ronald Palmer, MD 1:00pm – 1:30pm Rate Your Golf Swing against the Pro 1:00pm – 5:00pm La Federacion del Mano Inaugural Meeting 7:35am – 7:45am Overview – “When Can Recovery be Rapid?” Eduardo Zancolli, III, MD Brian Adams, MD Course is complimentary but pre-registration is required. Aviva Wolff, OTR/L, CHT 3:30pm – 5:30pm Bioskills Workshops 7:45am – 8:00am Outcomes - How Do We Measure Rapid Recovery? Sponsored by: Joy Macdermid, PT, PhD, CHT BW-I Current Techniques for PyroCarbon MCP/PIP/CMC Arthroplasty Wrist Injuries: “The Express Line” Course Description: Use of the Ascension MCP/PIP/PHS implants will be demonstrated Christine Novak, PT, Moderator in this workshop. The course is designed to provide a comprehensive overview of the PyroCarbon Implants, design rationale, patient selection, surgical technique and postop- 8:00am – 8:10am Scaphoid Fractures erative therapy. Cadaveric models will be used to demonstrate MCP/PIP/PHS implant Randall Culp, MD insertion and soft tissue repair. Course Objectives: Participants should have an understanding of indication, proper 8:10am – 8:20am Distal Radial Fractures technique and post operative therapy. Jorge Orbay, MD Faculty: Robert Beckenbaugh, MD Sponsored by:

8:20am – 8:35am Recovery After Wrist Fractures BW-2 Current Techniques for DRUJ Disorder Dorit H. Aaron, MA, OTR/L, CHT, FAOTA Course Description: Use of the Ascension First Choice DRUJ System will be demonstrat- 8:35am – 8:55am Ligament Injuries ed in this workshop. The course will introduce a new Partial Resurfacing implant designed to replace the articular region of the distal ulna. The course will provide a Richard Berger, MD, PhD comprehensive overview of DRUJ disorders, discuss both implant options offered in the Julianne Howell, PT, MS, CHT First Choice DRUJ System, the Partial Resurfacing implant and a Total Ulnar Head 8:55am – 9:10am Panel/Discussion Implant, design rationale, patient selection, surgical technique and postoperative thera- py. Cadaveric models will be used to demonstrate the surgical technique of both the Partial Resurfacing Implant and Total Ulnar Head Implant. 9:10am – 10:45am Digital Injuries – “Hold Fast” Course Objectives: Participants should have an understanding of Indication, proper Brian Adams, MD, Moderator technique and post operative therapy. Faculty: Brian Adams, MD 9:10am – 9:30am Metacarpal and Phalangeal Fractures Sponsored by: Michael Bednar, MD BW-3 Treatment of Distal Radius Fractures Terri Skirven, MS, OTR/L, CHT Course Description: There will be a surgical demonstration on the treatment of distal radius fractures using the OptiLock® Distal Radius Plating System with patented 9:30am – 9:50am PIP Fracture Dislocations SphereLockTM technology. Emphasis will be on indications, design rationale, surgical tech- Joseph Slade, MD nique, post-operative rehabilitation and follow-up. Paul Brach, MS, PT, CHT Faculty: Melvin P. Rosenwasser, MD

Sponsored by: 9:50am – 10:10am Extensor Tendon Injuries BW-4 Open and Arthroscopic Treatment of the Brian Adams, MD Thumb CMC Arthritis Julianne W. Howell, MS, PT, CHT Course Description: A number of different methods can be successfully used for treat- ment of osteoarthritis of the CMC joint. This workshop will focus on strategies for the 10:10am – 10:30am Flexor Tendon Injuries use of a minimally invasive approach to treat earlier stage OA utilizing a biodegradable Peter Amadio, MD resurfacing implant. Rebecca von der Heyde, MS, OTR, CHT Course Faculty: Randall Culp, MD

Sponsored by: 10:30am – 10:45 Panel/Discussion BW-5 Minimal Resection Total Wrist Arthroplasty; Surgical Technique and Case Review 10:45am – 11:00am Break with Exhibitors Course Description: Reproducible positive results with total wrist arthroplasty rely heav- ily on the instrumentation and surgical technique. A new, anatomic wrist instrumenta- Pediatric Injuries: “What Can We Learn From Kids?” tion system (and implant) will be presented, focusing on minimal bone resection and consistent results. 11:00am – 11:20am Upper Extremity Fractures: Hand, Wrist Course Faculty: William Cooney, MD and Forearm Sponsored by: Scott Kozin, MD BW-6 Hand & Upper Extremity Solutions Dorit H. Aaron, MA, OTR/L, CHT, FAOTA

Sports Injuries: “How the Athletes Do It – In a NY Minute” 6:00pm – 7:00pm AAHS Welcome Reception Susan Michlovitz, PT, PhD, CHT, Moderator See page 16 for details

26 SCAPHOID FRACTURES: RAPID RECOVERY – THE FAST TRACK RANDALL W. CULP, M.D.

I. Epidemiology 6 A. Among all wrist injuries, the incidence is second only to fractures of the distal radius fracture 17 B. Approximately 345,000 scaphoid fractures per year in the U.S. 19 C. Nearly 70% of carpal fractures involve the scaphoid 18 D. Annual incidence in Denmark: 38 per 100,000 men, 8 per 100,000 women 18 E. Average age group: 15-29 years 9 F. Nonunion rate of 92% in fractures displaced < 1 mm 20 G. Estimated that there are 17,250 to 34,500 nonunions per year despite proper treatment

II. Historical Perspective A. Nonoperative Treatment 1. Closed cast immobilization for stable non-displaced fracture a. The undisputed recommendation b. Union rate up to 95% c. Location of fracture determines healing time, duration immobilization10 1) Distal pole – 8 weeks 2) Waist – 12 weeks 3) Proximal pole – 5-6 months 8 d. 30 year follow up, 56 patients, 10% nonunion rate

2. Type of Immobilization: Support can be found for nearly every type of cast and position!!!! a. Wrist Position: volar flexion vs. dorsiflexion, ulnar deviation vs. 2, 6, 11, 16 radial deviation 1) No clinical data to support one wrist position over another 2) Typically fractures amenable to cast immboliziation are “stable” and require protection rather than reduction – probably explains why wrist position has little effect on union rates 3) Practially speaking – wrist position should be such that radiographs after cast application show anatomic coaptation of fracments, with normal carpal alignment b. Thumb spica cast (long or short) most commonly used 1) Long arm vs. short arm (Gellman 198910) a) Fractures of the middle or proximal third of the scaphoid-immobilization of the elbow resulted in significantly shorter time to union b) Fractures of the distal third – did well regardless of elbow inclusion 2) Forearm rotation in short arm cast induces fracture site 15 motion (cadaver study) c. Inclusion of additional digits 7 1) Dehne – inclusion of the index and middle finger 26 2) Taleisnik – include index/middle if “very unstable” 3) Clay5 – no difference in incidence of nonunion rates with or without thumb spica component

27 B. Operative Treatment 12, 13 1. Herbert & Fisher a. “New scaphoid screw” b. Volar approach c. 100% union rate in acute fractures 12-23 2. Rettig & Kollias a. 12 athletes, acute waist scaphoid fx, ORIF with Herbert screw b. Avg union rate 90% by 9.8 weeks c. Return to sports in less than 6 weeks All volar approaches require division of volar carpal ligaments!!!

III. Percutaneous Scaphoid Fixation A. Minimally invasive – avoids division of important volar carpal ligaments and excessive soft tissue dissection B. Indications 1. High Performance Athlete 2. “Critical need to return to work or activity” C. The Data – 1. Nondisplaced scaphoid waist fractures a. Bond, Shin, McBride Dao3 1) Prospective randomized study – cast vs. percutaneous screw fixation (25 patients) 2) Acute stable waist fractures 3) Time to healing with surgery 7.09 weeks vs. 11.62 weeks for cast (p=0.0003) 4) Return to military duty paralleled healing time (p=0.0001) 5) Minimal complications 6) No nonunions or delayed unions b. Adolfsson, Lindau, Arner1 1) Multicenter, prospective, randomized 2) 53 patients with undisplaced scaphoid waist fractures 3) Percutaneous Acutrak screw vs. cast immobilization (short arm cast) 4) No statistical difference between groups for rate of union and time to union (but radiographs not obtained at interval periods) 5) Improved motion at 16 weeks for screw group 6) No difference in grip strength 7) Acute fixation with percutaneous screw allows early mobilization without adverse affect on fracture healing 27 c. Yip, Wu, Chang, So 1) 49 patients with scaphoid waist stable fracture 2) volar percutaneous technique: AO screw or Alphatec screw 3) Average time to fracture union 12 weeks 4) 16 patients with trapezium erosion 2. Displaced Scaphoid Waist Fractures – volar Percutaneous Technique a. Jeon, Oh, Park, Ihn, Kim14 1) 13 displaced waist fracture 2) Volar, non-cannulated screw placement 3) Union at 9.2 weeks, 100% union 4) Return to work ranged from 1 day to 3 weeks 5) One case RSD

28 3. Arthroscopic Assisted Dorsal Percutaneous Techniques a. Slade, Gutow, Geissler25 1) 27 acute scaphoid fractures: 17 waist, 109 proximal pole 2) Arthroscopic assisted, dorsal percutaneous fixation 3) 100% union at 12 weeks

IV. Mini-Open Techniques A. Definition – what constitutes “mini-open” technique? 1. Is it an incision less than 2 cm, or is it a technique that does not violate ligamentous structures and avoids excessive tissue dissection? 2. Definition not standardized and as such, many techniques may be included in this category. B. Dorsal Mini-Open 1. Excellent for proximal pole scaphoid fracture 24 a. Rettig, Raskin 1) 17 patients 2) Acute unstable proximal pole 3) Retrograde fixation with Herbert Screw via dorsal approach 4) Average time to union 10 weeks 5) ORIF is better means than casting to reduce complications of delayed union, nonunion, osteonecrosis C. Volar Mini-Open 1. Techniques that utilize small incision to expose volar lip of scaphoid or used to ronguer portion of trapezium to gain access to scaphoid

V. Does Volar vs. Dorsal Matter? 4 A. Chan, McAdams 1. Cadaveric study to compare central positioning of screw via dorsal or volar percutaneous placement 2. Proximal dorsal placement allowed for more central placement of screw compared to volar, however authors conceded that it remained unclear if a more central screw placement translated to improved clinical outcome

29 REFERENCES 1. Adolfsson, L; Lindau T; Arner, M: Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures. J Hand Surg [Br], 26(3): 192-5, 2001.

2. Bao, JL: Wrist position in closed reduction of fractured carpal scaphoid. An experimental observation. Chin Med J [Engl], 105(1): 55-9, 1992.

3. Bond, CD; Shin, AY; McBride MT; and Dao, KD: Percutaneous screw fixation or cast immobilization for nondisplaced scaphoid fractures. J Bone Joint Surg, 83A: 263-277, 2001.

4. Chan KW and McAdams TR: Central screw placement in percutaneous screw scaphoid fixation: a cadaveric comparison of proximal and distal techniques. J Hand Surg [Am], 29(1): 74-9, 2004.

5. Clay, NR; Dias, JJ; Costigan, PS; Gregg, PJ; Barton, NJ: Need the thumb be immobilized in scaphoid fractures? A randomized prospective trial. J Bone Joint Surg, 73B: 828-832, 1991.

6. Cooney, WP; Dobyns, JH; Linscheid, RL: Fractures of the scaphoid: a rational approach to treatment. Clin Orthop, 149: 90-94, 1980

7. Dehne, E; Deffer, PA; Feighney, RE: Patho mechanics of the fracture of the carpal navicular. J Trauma, 4: 96-114, 1954.

8. Duppe, H; Johnell, O; Lundborg, G; Karlsson, M; Redlund-Johnell, I: Long-term results of fracture of the scaphoid. A follow-up study of more than thirty years. J Bone Joint Surg [Am], 76(2): 249-252, 1994.

9. Eddeland, A; Eiken, O; Hellgren, E; Ohlsson, NM: Fractures of the Scaphoid. Scan J Plast Reconst Surg, 9: 234-239, 1975.

10. Gellman, H; Caputo, RJ; Carter, V; Aboulafia, A; McKay, M: Comparison of short and long thumb-spica casts for non-displaced fractures of the carpal scaphoid [see comments]. J bone Joint Surg [Am], 71 (3): 354-7, 1989.

11. Hambidge, JE; Desai, VV; Schranz, PJ; Compson, JP; Davis, TR; Barton, NJ: Acute fractures of the scaphoid. Treatment by cast immobilization with the wrist in flexion or extension? J Bone Joint Surg [Br], 81 (1): 91-2, 1999.

12. Herbert, TJ; Fisher, WE: Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg, 66B: 114-123, 1984.

13. Herbert, TJ; Fisher, WE; Leicester, AW: The Herbert bone screw: a ten year perspective. J Hand Surg [Br], 17 (4); 415-9. 1992.

14 Jeon, IH; Oh, CW; Park, BC; Ihn, JC; Kim, PT: Minimal invasive percutaneous Herbert screw fixation in acute unstable scaphoid fracture. Hand Surg, 8(2): 213-8, 2003.

15. Kaneshiro, SA; Failla, JM; Tashman, S: Scaphoid fracture displacement with forearm rotation in a short-arm thumb-spica cast. J Hand surg [Am], 24(5); 984-91, 1999.

16. King, RJ; Mackenney, RP; Elnur, S: Suggested method for closed treatment of fractures of the carpal scaphoid: hypothesis supported by dissection and clinical practice. J R Soc Med, 75(11): 860-7, 1982.

17. Kuschner, SH; Lane, CS; Brien, WW; Gellman, H: Scaphoid fractures and scaphoid nonunion. Diagnosis and treatment. Orthop Rev, 23(11): 861-71, 1994.

30 18. Larson, CF; Brondum, V; Skov, O: Epidemiology of scaphoid fractures in Osense, Denmark. Acta Orthop Scand, 63: 216-218, 1992.

19. Lourie, GM: Carpal Fractures. In American Society for Surgery of the Hand: Hand Surgery Update 2. Edited by Light, TR, Rosemont, American Academy of Orthopaedic Surgeons, 1999.

20. Osterman, AL; Mikulics, M: Scaphoid nonunion. Hand Clin, 14: 437-455, 1988.

21. Rettig, AC: Fractures in the hand in athletes. Instr Course Lect, 47: 187-90, 1998.

22. Rettig, AC; Kollias, SC: Internal fixation of acute stable scaphoid fractures in the athlete. Am J Sports Med, 24(2): 182-6, 1996.

23. Rettig, AC; Weidenbener, EJ; Gloyeske, R: Alternative management of mid-third scaphoid fractures in the athlete. Am J Sports Med, 22(5): 711-4, 1994.

24. Rettig, ME, Raskin, KB: Retrograde compression screw fixation of acute proximal pole scaphoid fractures. J Hand Surg [Am], 24(6): 1206-10, 1999.

25. Slade, JF, 3rd; Gutow, AP; Geissler, WB: Percutaneous internal fixation of scaphoid fractures via an arthroscopically assisted dorsal approach. Bone Joint Surg [Am], 84-A, Suppl 2: 21-36, 2002.

26. Taleisnik, J: The Wrist. pp. 118, Edited 118, New York, Churchill Livingstone, 1985.

27. Yip, HS; Wu, WC; Chang, RY; So, TY: Percutaneous cannulated screw fixation of acute scaphoid waist fractures. J Hand Surg [Br], 27(1): 42-6, 2002.

31 The Treatment of Unstable Distal Radius Fractures with the DVR Plate and the Extended FCR Approach

Orbay J.L, Badia A., Indriago I., Khouri R.K., Gonzalez E., and Fernandez D.L.

Introduction: We present our clinical experience with a new internal fixation method for the general treatment of the unstable distal radius fracture. The DVR plate applied through the extended FCR approach allows the volar management of complex distal radius fractures regardless of their direction of instability. This technique provides stable internal fixation and allows early function while avoiding the extensor tendon problems that have plagued dorsal plate fixation.

Methods: We treated unstable distal radius fractures, mostly dorsally displaced, through the extended FCR approach. This is an extension of the classic FCR approach in which dorsal exposure is obtained by releasing the radial septum and mobi- lizing the proximal radius. It provides sufficient exposure to manage articular displacement, apply bone graft and treat nas- cent malunions. Internal fixation was provided by the DVR plate, which is a fixed angle device, designed for volar fixation of dorsally unstable distal radius fractures.

Results: We followed 127 patients presenting with 136 unstable distal radius fractures for an average of 27 weeks. All cases were treated with the DVR plate through the extended FCR approach. The fractures were classified according to the “Comprehensive Classification of Long Bone Fractures” and to the direction of instability. The clinical results were evalu- ated radiographically and functionally. The average final range of motion was 60 deg. of dorsiflexion, 58 deg. of volar flex- ion, 82 deg. of pronation and 79 deg. of supination. The grip strength was 77% of the contralateral side. No external fix- ation was needed. Functional use of the hand was allowed on the first post-op week. Splinting was utilized for four weeks. There were no cases of plate failure or loss of reduction. Complications consisted of one case of dorsal tendon irritation from an excessive long peg, treated by hardware removal and two cases of transient regional pain syndrome.

Conclusion: The general treatment of unstable distal radius fractures with internal fixation and early function is possible with the use of the DVR plate and the extended FCR approach. This technique presents a low complication rate and min- imizes tendon problems.

32 Recovery after Wrist Fractures: Post Op Management of DRFx and Scaphoid Fx Dorit H. Aaron, MA, OTR, CHT, FAOTA AAHS PR 2006 [email protected]

References:

Aaron DH, Stegink-Jansen CW (2000). Rehabilitation: Matching Patient Priorities & Performance with & Tissue Healing. OT Practice 5(8), 11-15.

Dell PC, Dell RB (2002). Management of Carpal Fractures and Dislocations. Rehabilitation of the Hand and Upper Extremity: 5th Ed. Editors: Mackin, Callahan, Skirven, Schneider, Osterman. Mosby, St. Louis. 1171-1184.

Harris JE, MacDermid JC, Roth J (2005). The International Classification of Functioning as an explanatory model of health after distal radius fracture: a cohort study. Helath Qual Life Outcomes. Nov;3-73

Lichtman DM, Alexander AH (1997). Part IX: Wrist Therapy & Rehabiliation. The Wrist & Its Disorders.WB Saunders, Philadelphia. 693-714.

Laseter, GF (2002). Therapist’s Management of Distal Radius Fractures. Rehabilitation of the Hand and Upper Extremity: 5th Ed. Editors: Mackin, Callahan, Skirven, Schneider, Osterman. Mosby, St. Louis. 1136-1155.

LaStayo PC, Chidgey LK(Editors) (1996). The Wrist: Special Issue. Journal of Hand Therapy. 9(2), 81-183.

MacDermid, JC, Richards, R.S., Roth, JH (2001). Distal Radius Fracture: A Prospective Outcome Study of 275 Patients. Journal of Hand Therapy, Vol 14(2), p 154-169.

Michlovitz, SL, LaStayo, PC, Alzner, S, Watson, E. (2001). Distal Radius Fractures: Therapy Practice Patterns. Journal of Hand Therapy. Vol 14(4), p249-257.

Orbay JL, Touhami A (2006). Current concepts in volar fixed-angle fixation of t unstable distal radius fractures. Clin Orthop Rleat Res. Apr;445:58-67

Rosental TD, Blazar PE (2006). Functional outcome and complications after volar plating for dorsally displaced, unstable fractures of the distal radius. J Hand Surg (Am). Mar; 31(3):359-65

Skirven TM, Osterman AL, (2002). Clinical Examination of the Wrist. Rehabilitation of the Hand and Upper Extremity: 5th Ed. Editors: Mackin, Callahan, Skirven, •Schneider, Osterman. Mosby, St. Louis. 1099-1116.

Smith, DW, Brou, KE, Henry, MH (2004). Early Active Rehabilitation for Operatively Stabilized Distal Radius Fractures. Journal of Hand Therapy. Vol 17(1), p 43-49.

Ustunb T.B., World Health Organization, Geneva, Switzerland

Kimberly Goldie Staines, OTR, CHT for selected photos.

Dorit H. Aaron, MA OTR CHT FAOTA Houston, Texas USA

33 Metacarpal and Phalangeal Fractures Michael S. Bednar, MD Chief, Section of Hand Surgery Associate Professor Dept. of Orthopaedic Surgery and Rehabilitation Loyola University – Chicago

Introduction Incidence – metacarpal and phalangeal fractures – 10% of all fractures Location Distal phalanx (45-50%) Metacarpal (30-35%) Proximal phalanx (15-20%) Middle phalanx (8-12%) “Phalangeal fracture of the hand. An analysis of gender and age-related incidence and aetiology.” De Jonge. JHS 19B, 1994. 10-29 y.o. – sports 40-60 y.o. – industrial injures, highest incidence >70 y.o. – accidental falls Classification of phalangeal fractures – modified from Belsky, Jupiter, Axelrod

Location Pattern Skeleton Deformity Soft tissue Assoc Injury Reaction to Motion base transverse simple angulation closed skin stable shaft oblique impacted dorsal/palmar open tendon unstable neck spiral comminuted lateral avulsion ligament head avulsion bone loss malrotation burnnerve physis shortening crush blood vessel

X-rays AP and true lateral of individual digit Oblique helpful when fracture close to joint Pre-and post-reduction views Management Considerations Associated soft tissue injury Age of: Patient Injury Associated diseases Patient motivation Socioeconomic factors Principles of treatment Accurate fracture reduction Movement of uninvolved fingers to prevent stiffness Elevation of extremity to limit edema Immobilization in intrinsic positive position Early remobilization of injured finger Fracture consolidation Closed non-displaced fracture – protected motion can start within the first 21 days depending on stability Fractures of diaphyseal phalanges have prolonged healing times Middle phalanx – 10-14 weeks Proximal phalanx – 5-7 weeks Comminuted fractures and those requiring ORIF take longer to consolidate

34 Metacarpal Fractures Metacarpal Shaft Fractures Stable splint, fracture brace, cast include wrist and MP joint Unstable Longitudinal percutaneous Kirschner wire Oblique percutaneous Kirschner wire Transverse Kirschner wires inserted into neighboring metacarpal Intramedullary rods Inteosseous wire Lag screws Plate Goals of treatment Least invasive procedure Simplest Produces least amount of soft tissue injury Attain sufficient stability Promote union Allow motion

Metacarpal Neck Fractures Ring and Small Finger <15 – ulnar gutter splint 10-14 days 15-40 – reduce and apply splint >40 – percutaneous pinning, ORIF Index and Middle Finger >15 - ORIF

Phalangeal Fractures Phalangeal shaft fractures Nondisplaced and stable Majority of fractures Cast, or splint with buddy tape Follow closely over 3-4 weeks for evidence of displacement Angulation .>10∞ Shortening < 2 mm Bone appostion > 50% Any malrotation Displaced transverse and short oblique fractures Proximal phalanx Longitudinal pinning thru metacarpal head Belsky, Eaton, Lane. JHS 9A, 1984 0.035 “ (1.0 mm) or 0.045” (1.1 mm) pin is passed on one side of the extensor tendon joint must be reduced and compressed before advancement of wire Pin ends in subchondral bone of proximal phalanx at PIP joint Use adjacent fingers for control of rotation thru the fracture Cast or splint for 3 weeks Crossed K-wire placement Configuration provides most resistance to torsion and distraction in transverse fractures, equal to longi- tudinal wires for bending Viegas, et al. J Hand Surg 13A, 1988 In proximal phalanx, easier to place for phalangeal base fractures, more difficult for midshaft fractures

35 Method of choice for middle phalanx fractures Long consolidation time for fracture Allows early ROM of PIP and DIP joints Multiple planes For oblique fractures Pins perpendicular to fracture resist bending, torsion, and distraction Pins placed perpendicular to fracture resists compressive load Intramedullary nailing Gonzalez, et al. J Hand Surg 20A, 1995 Multiple pre-bent 0.8 mm are passed proximally to distally thru drill holes made near the MP joint 2-3 rods are placed into the proximal phalanx and end at the subchondral bone distally rod is cut flush with the bone proximally hand is placed in a dorsal MP blocking splint for 4 weeks and begins immediate PIP motion results average angulation 2∞, worst 12 lateral angulation, 4∞hyperextension average AROM of PIP 89∞ 4 pts. with flexion contracture of PIP joint, worst 20 TAM 238∞, (191∞ –269∞) Long oblique fracture Definition - fracture whose length is twice the diameter of the bone at the fracture site When closed reduction possible: Hold reduction with percutaneous reduction clamp Insert multiple K-wires perpendicular to the bone and fracture Insert > 2 lags screws, each separated by 2 head diameters

Phalangeal neck fracture May occur at middle or proximal phalanx Phalangeal head is hyperextended Failure to treat leads to permanent loss of flexion Technique Place K-wire longitudinally thru distal phalanx Hyperextend distal bone thru IP joint to capture head of fractured phalanx Reduce fracture by inserting pin down the shaft of the broken phalanx

Complications Pin tract infection Reported as high as 18% Botte, et al, Clin Orthop, 276, 1992 No tension should be present at pin exit site Infection more likely when patient splinted and motion at pin site allowed Flexion contracture More likely when fracture is near PIP joint More likely with soft tissue disruption

36 References:

J. Agee. Treatment principles for proximal and middle phalangeal fractures. Orthopedic Clinics of North America.1992;1:35-40.

E. Beatty, T. R. Light, R. J. Belsole and J. A. Ogden. Wrist and hand skeletal injuries in children .Hand Clinics.1990;4:723-38.

M. R. Belsky, R. G. Eaton and L. B. Lane. Closed reduction and internal fixation of proximal phalangeal fractures. Journal of Hand Surgery - American Volume.1984;5:725-9.

M. J. Botte, J. L. Davis, B. A. Rose, H. P. von Schroeder, H. Gellman, E. M. Zinberg and R. A. Abrams. Complications of smooth pin fixation of fractures and dislocations in the hand and wrist. Clinical Orthopaedics & Related Research.1992;276:194-201.

B. K. Bryan and E. N. Kohnke. Therapy after skeletal fixation in the hand and wrist. Hand Clinics.1997;4:761-76.

J. T. Capo and H. Hastings, 2nd. Metacarpal and phalangeal fractures in athletes. Clinics in .1998;3:491- 511.

J. J. De Jonge, J. Kingma, B. van der Lei and H. J. Klasen. Phalangeal fractures of the hand. An analysis of gender and age-related incidence and aetiology. Journal of Hand Surgery - British Volume.1994;2:168-70.

M. W. Elmaraghy, A. W. Elmaraghy, R. S. Richards, S. J. Chinchalkar, R. Turner and J. H. Roth. Transmetacarpal intramedullary K-wire fixation of proximal phalangeal fractures. Annals of Plastic Surgery.1998;2:125-30.

A. E. Freeland, W. B. Geissler and A. P. Weiss. Surgical treatment of common displaced and unstable fractures of the hand. Instructional Course Lectures.2002;185-201.

M. H. Gonzalez and R. F. Hall, Jr. Intramedullary fixation of metacarpal and proximal phalangeal fractures of the hand. Clinical Orthopaedics & Related Research.1996;327:47-54.

M. H. Gonzalez, C. M. Igram and R. F. Hall. Intramedullary nailing of proximal phalangeal fractures. Journal of Hand Surgery - American Volume.1995;5:808-12.

S. H. Kozin, J. J. Thoder and G. Lieberman. Operative treatment of metacarpal and phalangeal shaft fractures. Journal of the American Academy of Orthopaedic Surgeons.2000;2:111-21.

S. G. Lee and J. B. Jupiter. Phalangeal and metacarpal fractures of the hand. Hand Clinics.2000;3:323-32.

H. S. Matloub, P. L. Jensen, J. R. Sanger, B. K. Grunert and N. J. Yousif. Spiral fracture fixation techniques. A biome- chanical study. Journal of Hand Surgery - British Volume.1993;4:515-9.

S. F. Viegas, E. L. Ferren, J. Self and A. F. Tencer. Comparative mechanical properties of various Kirschner wire configura- tions in transverse and oblique phalangeal fractures. Journal of Hand Surgery - American Volume.1988;2:246-53.

37 AAHS SPECIALTY DAY PROGRAM 2007 “Pilon & PIP Fracture- Dislocation” Joseph F. Slade, III, MD Associate Professor & Director Hand and Upper Extremity Service Department of Orthopaedics & Rehabilitation Yale University School of Medicine [email protected] “Rapid Recovery- The Fast Track” 9:30-9:50AM

AAHS 2007 ANNUAL MEETING PUERTO RICO Wednesday, January 10th, 2007 Introduction Pilon fractures are comminuted intra-articular fractures of the base of the middle phalanx. These fractures are a result of axial loading which cause a disruption of articular rim of the base of the middle phalanx both the dorsal and volar articular surface. This injury results in central articular depression and widening of the base of the proximal pha- lanx. Stern reported that pilon fractures treated with external fixation resulted in similar results from those treated with ORIF, but without the associated complications of open repair. Salter determined that early motion of articular injuries resulted in healing and remodeling of an injured joint surface. Schenck applied Salter’s principles and design an orthot- ic traction splint which permitted passive motion while applying continuous traction. This traction splint used ligamen- totaxis to mold the injured base of the middle phalanx articular surface to the condyles of the proximal phalanx during healing. There were two concerns about continuous traction in the treatment of pilon fractures. The first, was the abili- ty of traction alone to prevent levering at the fracture site as it attempted to glide around the Condyles. The second, was the force required to maintain reduction. These problems were solved by the placement of a fulcrum just distal to the fracture site. The application of a lever reduces the forces required to maintain fracture reduction. The fulcrum also acts as a check to joint subluxation as the joint glides through a full arc of motion. The dynamic traction external fixa- tor maintains congruent reduction of a pilon fracture while restoring hand function by permitting early initiation of both active and passive motion protocols.

Anatomy of PIP Joint The PIP joint is a constrained hinge joint whose stability is conferred by both the matched bone contouring at the joint inter- face and the capsular complex composed of stout lateral cords and mobile volar plate. The head of the proximal phalanx is cam shaped and composed of a bicondylar head with a central groove. The doubly concave surface of the base of the middle phalanx is divided by a midline tongue to guide the joint through its eccentric arc of motion. The main lateral stabilizer of this joint is the proper collateral ligament. This ligament originates from the head of the proximal phalanx and inserts into the base of the middle phalanx. The proper collateral ligament is joined to the volar plate by shroud-like fibers of the accessory collateral ligament. These two structures function as a composite unit to resist both the lateral and hyperextension stresses on the joint. In extension the volar plate is tight and the col- lateral ligament is moderately lax. As the joint flexes the collateral ligament tightens over the larger volar condlyes to seat the base of the middle phalanx firmly against the proximal phalangeal head. In flexion, the volar plate is lax. The average ROM at the PIP joint is approximately 110 degrees.

38 Mechanics of Injury The mechanism of injury most commonly associated with pilon fractures of the PIP joint is a sudden axial loading to the extend- ed digit. These injuries include dorsal , volar and combined rimmed fractures which permits a widening of the shattered base. Cadaveric studies in our lab identified dorsal fracture –dislocations and the pilon fracture s as the most common injuries sus- tained when an sudden axial load was applied to a digit. Dorsal fracture –dislocations were most common when a fully extended PIP was axially impacted . This is due in part to the laxity of the collateral ligaments when the joint is in full extension, permitting increased dorsal translation of the middle phalanx and an increased load on its volar surface and the volar plate. With a hyperextension moment on the PIP joint, the base of the middle phalanx is forced dorsally resulting in a shearing of its volar base on the proximal phalangeal head and a dorsal dislocation of the joint. With flexion of the PIP joint the base of the proximal phalanx is more firmly seated and axial loading resulted in a significant increase in the number of pilon fractures generated following injury, both the intrinsic and extrinsic tendon systems act as deform- ing forces on the joint. The strong sublimus insertion causes a flexion moment on the distal portion of the middle phalanx, while the lateral bands tend to collapse the joint in flexion and rotate the proximal end of the middle phalanx dorsally. These forces explain the difficulty in maintaining a concentric reduction. To maintain a reduction, treatment must re-balance these forces . To allow motion of the injured joint, the stabilizing forces must be realized throughout the full arc of motion. Treatment Options for Pilon Fractures Extensive comminution makes anatomic restoration of the articular surface impossible. The goal is restoration of a congruent gliding surface.

1. Splinting- results in stiffness 2. Traction dynamic traction external fixator span the pip joint and permit early active motion orthotic traction splint passive motion only

ORIF Standard ORIF- increase complications Limited ORIF to restore central depression bone graft- as needed Dynamic external fixator

Volar Arthroplasty Boney reconstruction of Dorsal rim Dynamic external fixator

Hemi-Hamate Chondral Arthroplasty Dynamic external fixator

Technique of Application of PIP Dynamic Distraction External Fixation: Manual closed reduction is performed on the injured digit. If closed reduction of the proximal interphalangeal joint is unattainable, a percutaneous reduction can be accomplished using minimal incisions with fluroscopic guidance. Concentric reduction of the joint must be obtainable prior to frame application. The dynamic distraction splint is assembled using three 0.045-inch K-wires placed parallel to each other and perpendicular to the lateral axis of the digit (figure). The lateral axis of the finger is a plane where the dorsal forces acting on the skin are perfectly balanced by the palmar forces, resulting in minimal soft tissue gliding and important feature in pin placement to reduce pin tract infection. Using a mini C-arm fluoroscopy for pin placement, the first K-wire is placed through the rotational center of the head of the prox- imal phalanx as seen on the lateral fluoroscopic view. The free ends of the wire on both sides are bent at right angles and distally along the long axis of the digit. The ends of the wire are formed into hooks for application of the dental loop rubber bands.

39 A second parallel 0.045-inch k-wire is passed through the distal metaphysis or condlye of the middle phalanx. The free ends of this wire are also bent at a right angle and directed distally. This wire is parallel to the first wire and its ends are also fashioned into hooks for attachment of the dental loops. The proximal and distal pins are bent into hook form with a distance between the hooks of 2.5 cm. These two wires bridge the joint and with the dental loop rubber bands become the engine for continuous distraction to maintain concentric joint reduction. Ligamentous traction maintains reduction by transferring the forces of distraction to the surrounding soft tissue of the joint, which hold the fracture alignment. The final K-wire is parallel to other two wires and passes through the mid-diaphysis of the middle phalanx in the mid-axial line. Its free ends are cut short and bent around the limbs of the first wire to maintain the alignment of the first wire in the same plane with the digit as it courses through its flexion and extension arc of motion. This wire is provides a palmar translatory moment to aid in balancing the dorsally-directed forces of displacement. Dental loop rubber bands are then applied between the two hooks in sufficient quantity (usually three for each pair of hooks) to distract the joint and maintain its reduction throughout full range of motion. Joint reduction through a com- plete arc of motion is confirmed with radiographic imaging.

Postoperative Management Post-operatively, successful restoration of hand function is greatly aided by supervised hand therapy for both active and passive motion at both interphalangeal joints. Patients are started on an immediate gentle motion protocol within a few days following surgery as swelling decreases and joint motion increases . Weekly radiographs are obtained to confirm joint reduction . If dorsal subluxation is identified, applying more dental loop rubber bands until reduction is obtained increases traction. This is a powerful distraction device, and if over distrac- tion is detected, the number of rubber bands used for traction is reduced. Local wound care to pin tract sites is provided once a day with dilute hydrogen peroxide and sterile cotton swabs. The use of medicated ointments for pin tract care is not recommended, as these compounds pre- vent drainage, and may cause contact dermatitis with prolonged use. It has been shown with this dynamic splint that full recovery of flexion can be attained . Strict compliance with a supervised hand rehabilitation program is critical if patients are to regain full active extension of the PIP joint. The device is removed when radiographs demonstrate bony union, usually at five to six weeks. Prior to device removal, lateral radi- ographs with the rubber bands removed are obtained in full flexion and extension to confirm that concentric joint reduction is maintained out of traction . Therapy is continued after splint removal for one to two months, to recover motion and strengthen the hand.

Results We reported on a series of 9 fracture-dislocations of the PIP joint , treated with this dynamic distraction external fixation device. All fractures healed without complications recurrent dorsal dislocation or infection. Average flexion measured 94 degrees (range 85 to 115) and average extension deficit measured 14.5 degrees (range 0 to 35). DIP motion averaged 60 degrees of flexion and 9.5 degrees extension lag. One patient required a return to the operating room at 5 months for extensor tenolysis, and had restoration of active extension measuring 7 degrees. While all patients recovered functional digital flexion, there was a marked improvement in recovery of extension among the 5 patients treated with supervised hand therapy when compared with a group of 4 patients treated exclusively with a home exercise program.

Figures Below are schematic representation and photographs of the dynamic traction external fixator created intraoperatively from Kirschner wires and dental bands that spans the proximal interphalangeal joint and provides continuous traction throughout a full range of motion of the joint. The dynamic distraction splint is assembled using three 0.045-inch Kirschner wires placed parallel to each other and perpendicular to the lateral axis of the digit. Arrow A points to the placement of the first 0.045 inch K-wire is placed through the rotational center of the head of the proximal phalanx and is parallel to the joint surface. Arrow B points to the placement of the 2nd wire, also parallel to the joint surface of DIP joint and the first wire. The free ends of both wires are fashioned into hooks for attachment of the dental loops rubber bands. The dis- tance between the hooks is 2.5cm. The final wire is parallel to the other two wires and passes through the middle phalanx in the mid-axial line. Its free ends are cut short and bent around the limbs of the first K-wire. This pin acts as a fulcrum to maintain congruent reduction through a full arc of motion. Dental loop rubber bands are then placed between the two hooks in sufficient quantity (usually three per pair of hooks) to distract the joint and maintain its reduction throughout full range of motion. Finally, joint reduction through a complete arc of motion is confirmed with radiographic imaging.

40 Reference:

1. Hastings H II, Ernst JMJ: Dynamic External Fixation for Fractures of the Proximal Interphalangeal Joint. Hand Clinics. Nov. 1993; Vol. 9(4): 659-674.

2. Krakauer JD, Stern PJ: Hinged Device for Fractures Involving the Proximal Interphalangeal Joint. Clin. Orthop. Rel. Res. 1996; No.327: 29-37.

3. Schenck RR: Dynamic traction and early passive movement for fractures of the proximal interphalangeal joint. J Hand Surg 1986; 11A: 850-858.

4. Schenck RR: The Dynamic Traction Method. Hand Clinics. May 1994;10(2): 187-198.

5. Schuind F, Cooney WP III, Burny F, An KN: Small External Fixation Devices for the Hand and Wrist. Clin Orthop Rel Res. 1993; No.293: 77-82.

6. Slade JF 3d, Chrostowski JH, Pomerance J, Mc Auliffe J, Wolfe SW: Treatment of Unstable Fractures of the Proximal Interphalangeal Joint with Dynamic Traction and Immediate Active Motion. Orthopaedic Transactions 19(1): 127; 1995.

7. Slade, JF 3d; Gutow, A; Cohen, M; Wolfe, SW: Can a Distractor/Fixator Prevent Dorsal Subluxation of PIP Fracture-Dislocations? Orthop Trans.19(3):828, 1996.

8. Slade, JF 3d; Choi, JY; Wolfe, SW: A Cadaveric Model of the Unstable Fracture-Dislocation of the Proximal Interphalangeal Joint . Orthop Trans.21(1):120, 1997.

9. Slade, JF 3d; Choi, JY; Panjabi, MM; Wolfe, SW: The Influence of Joint Position on Fracture Type and Soft Injuries of Proximal Interphalangeal Joint Injuries. Orthop Trans.21(1):349, 1997.

10. Slade, JF 3d; Wolfe, SW; Gutow, A: Dynamic Distraction Fixation of Unstable Fractures of the PIP Joint. (Movie)-Copyright ASSH, 17 minutes, 1996.

11. Stern PJ, Roman RJ, Kiefhaber TR, McDonaough JJ: Pilon Fractures of the Proximal Interphalangeal Joint. J Hand Surg. 1991;16A: 844-850.

12. Wolfe SW, Katz LD: Intra-articular impaction fractures of the phalanges. J Hand Surg. 20A:327-333.

41 New Techniques for Flexor Tendon Rehabilitation Peter C. Amadio, MD

What Happens with No Rehabilitation The tendon Heals It doesn’t move well

The purpose of Rehabilitation Increase Tendon Excursion Either promote or at least not interfere with healing

Interaction of Patient Injury Repair/surgical technique Therapy/therapist

Modalities Passive Motion Active Motion Synergistic/Hybrid methods Loading/Mechanical stimulation Physical Ultrasound/Other

Modified Synergistic Therapy (Tanaka/Zhao)

42 References Boyer, M. I., R. H. Gelberman, et al. (2001). “Intrasynovial flexor tendon repair. An experimental study comparing low and high levels of in vivo force during rehabilitation in canines.” Journal of Bone & Joint Surgery - American Volume. 83-A(6): 891-9. Boyer, M. I., J. W. Strickland, et al. (2003). “Flexor tendon repair and rehabilitation: state of the art in 2002.” Instructional Course Lectures. 52: 137-61. Dobbe, J. G., N. E. van Trommel, et al. (1999). “A portable device for finger tendon rehabilitation that provides an iso- tonic training force and records exercise behaviour after finger tendon surgery.” Medical & Biological Engineering & Computing. 37(3): 396-9. Dobbe, J. G., N. E. van Trommel, et al. (2002). “Patient compliance with a rehabilitation program after flexor tendon repair in zone II of the hand.” Journal of Hand Therapy. 15(1): 16-21. Elliot, D. (2002). “Primary flexor tendon repair—operative repair, pulley management and rehabilitation.” Journal of Hand Surgery - British Volume. 27(6): 507-13. Gelberman, R. H., M. I. Boyer, et al. (1999). “The effect of gap formation at the repair site on the strength and excursion of intrasynovial flexor tendons. An experimental study on the early stages of tendon-healing in dogs.” Journal of Bone & Joint Surgery - American Volume. 81(7): 975-82. Goldfarb, C. A., F. Harwood, et al. (2001). “The effect of variations in applied rehabilitation force on collagen concentra- tion and maturation at the intrasynovial flexor tendon repair site.” Journal of Hand Surgery - American Volume. 26(5): 841-6. Grewal, R., S. S. Saw, et al. (1999). “Passive and active rehabilitation for partial lacerations of the canine flexor digitorum profundus tendon in zone II.” Journal of Hand Surgery - American Volume. 24(4): 743-50. Rosberg, H. E., K. S. Carlsson, et al. (2003). “What determines the costs of repair and rehabilitation of flexor tendon injuries in zone II? A multiple regression analysis of data from southern Sweden.” Journal of Hand Surgery - British Volume. 28(2): 106-12. Zhao, C., P. C. Amadio, et al. (2002). “Remodeling of the gliding surface after flexor tendon repair in a canine model in vivo.” Journal of Orthopaedic Research. 20(4): 857-62. Zhao, C., P. C. Amadio, et al. (2002). “Effect of synergistic motion on flexor digitorum profundus tendon excursion.” Clinical Orthopaedics & Related Research.(396): 223-30.

43 New Techniques for Flexor Tendon Repair in Zone 2 Peter C. Amadio, MD

Core Sutures Multiple Strands: 4 vs 2 or 6 Suture Caliber: 3-0 Locking Loops: YES

Novel Materials Suture Placement Repair at a Distance (Brunelli) Knot Placement: NOT palmar

Peripheral Sutures Locking Loops: YES FDS Repair in Zone 2: MGH Repair of ONE SLIP; remove the other?

Partial Lacerations: Trimming Surface Modification/Lubrication

44 References Angeles, J. G., H. Heminger, et al. (2002). “Comparative biomechanical performances of 4-strand core suture repairs for zone II flexor tendon lacerations.” Journal of Hand Surgery - American Volume. 27(3): 508-17. Barrie, K. A., S. L. Tomak, et al. (2000). “The role of multiple strands and locking sutures on gap formation of flexor tendon repairs during cyclical loading.” Journal of Hand Surgery - American Volume. 25(4): 714-20. Churei, Y., T. Yoshizu, et al. (1999). “Flexor tendon repair in a rabbit model using a “core” of extensor retinaculum with synovial membrane. An experimental study.” Journal of Hand Surgery - British Volume. 24(3): 267-71. Hatanaka, H. and P. R. Manske (1999). “Effect of the cross-sectional area of locking loops in flexor tendon repair.” Journal of Hand Surgery - American Volume. 24(4): 751-60. McLarney, E., H. Hoffman, et al. (1999). “Biomechanical analysis of the cruciate four-strand flexor tendon repair.” Journal of Hand Surgery - American Volume. 24(2): 295-301. Momose, T., P. C. Amadio, et al. (2000). “The effect of knot location, suture material, and suture size on the gliding resistance of flexor tendons.” Journal of Biomedical Materials Research. 53(6): 806-11. Momose, T., P. C. Amadio, et al. (2001). “Suture techniques with high breaking strength and low gliding resistance: experiments in the dog flexor digitorum profundus tendon.” Acta Orthopaedica Scandinavica. 72(6): 635-41. Moneim, M. S., K. Firoozbakhsh, et al. (2002). “Flexor tendon repair using shape memory alloy suture: a biomechanical evaluation.” Clinical Orthopaedics & Related Research.(402): 251-9. Paillard, P. J., P. C. Amadio, et al. (2002). “Gliding resistance after FDP and FDS tendon repair in zone II: an in vitro study.” Acta Orthopaedica Scandinavica. 73(4): 465-70. Papaloizos, M. Y., N. Scharer, et al. (2000). “Cross stitch peripheral tendon repair: a mechanical comparison with core stitch techniques.” Chirurgie de la Main. 19(2): 128-33. Singer, G., E. Ebramzadeh, et al. (1998). “Use of the Taguchi method for biomechanical comparison of flexor-tendon- repair techniques to allow immediate active flexion. A new method of analysis and optimization of technique to improve the quality of the repair.” Journal of Bone & Joint Surgery - American Volume. 80(10): 1498-506. Smith, A. M. and D. M. Evans (2001). “Biomechanical assessment of a new type of flexor tendon repair.” Journal of Hand Surgery - British Volume. 26(3): 217-9. Tang, J. B., C. Z. Pan, et al. (1999). “A biomechanical study of Tang’s multiple locking techniques for flexor tendon repair.” Chirurgie de la Main. 18(4): 254-60. Taras, J. S., J. S. Raphael, et al. (2001). “Evaluation of suture caliber in flexor tendon repair.” Journal of Hand Surgery - American Volume. 26(6): 1100-4. Veitch, A., K. Firoozbakhsh, et al. (2000). “In vitro biomechanical evaluation of the double loop suture for flexor tendon repair.” Clinical Orthopaedics & Related Research.(377): 228-34. Winters, S. C., R. H. Gelberman, et al. (1998). “The effects of multiple-strand suture methods on the strength and excur- sion of repaired intrasynovial flexor tendons: a biomechanical study in dogs.” Journal of Hand Surgery - American Volume. 23(1): 97-104. Xie, R. G., S. Zhang, et al. (2002). “Biomechanical studies of 3 different 6-strand flexor tendon repair techniques.” Journal of Hand Surgery - American Volume. 27(4): 621-7.

45 RAPID RECOVERY: Pediatric Injuries Upper Extremity Fractures: Hand Wrist and Forearm Hand Therapy Dorit Haenosh Aaron, MA OTR CHT FAOTA AASH, PR 2006 Houston, Texas [email protected]

SUMMARY •Children heal faster and more efficiently then adults •Children with UE fx rarely need formal therapy, usually they are referred for therapy if there are compli- cations such as persistent pain, decreased ROM, or refusal to use the hand. •Care taker of a child has a primary role in the rehabilitative process of a child •Children do not always understand why certain things are done “to them” and therefore may not be cooperative •In post op cases, children must first understand to “do no harm” to a healing part •Therapy must take the form of “play” whenever possible •Most fractures heal uneventfully and therapy, if needed, consists of splinting and a home program •Splinting fabrication needs to take in to consideration the “Houdini Effect”

REFERENCES •**Aaron D (2006). Pediatric Hand Therapy. In Henderson and Pehoski’s editors: Hand Function in the Child, Foundations for Remediation ((367-400). St Louis, Mosby. •Davis JL, Crick JC (1988). Pediatric hand injuries. Type and general treatment considerations. AORN Jr, 48 (2):237-239, 242-235, 248-249 •Mahbir RC et al (2001). Pediatric hand fractures: a review. Pediatr Emerg Care, 17(3):153-6 •Thompson T (2004). Strategies and techniques to enhance wearing compliance of splints in . Advance for OT Practitioners, 17:15-15 •Valencia J, Leyva F, Gomez-Bajo GJ (2005). Pediatric Hand Trauma. Clin Orthop Relat Res. (432):77-86 •Roberts A (2000). Special Considerations in Children’s Fractures. In Gupta A at al editors: The Growing Hand (519-530). St Louis, Mosby •Most of the art in this presentation was done by the children of Schneider Children’s Hospital In Israel www.schneider.org.il THANK YOU!

46 Pediatric Upper Extremity Fractures Scott Kozin, MD Dorit H. Aaron, MA, OTR/L, CHT American Association for Hand Surgery Specialty Day 2007 Rapid Recovery- The Fast Track

I. Properties of Children a. Different than adults b. Short attention span c. Honest, open, and love life d. Literal interpretation e. No secondary gain f. Literal interpretation g. Loose- tend NOT to stiffen!!!!!!! II. Evaluation of Stiffness in Children a. Why?? b. Evaluation i. History of injury ii. Treatment iii. Immobilization- length and position c. X-rays/ Advanced imaging studies III. Treatment- non-operative a. Time and patience b. Time for remodeling c. Therapy i. Low load prolonged stretch ii. Total end range time iii. Modalities d. Exercise- play!! IV. Treatment- operative a. Correct underlying deformity b. Restore anatomy c. Joint release d. Arthroplasty- resurfacing V. A Glimpse in to the Future a. What can we learn form children? b. Fetal healing c. Beredjiklian et al References Brink HE, Miller GJ, Beredjiklian PK, Nicoll SB. Serum-dependent effects on adult and fetal tendon fibroblast migration and collagen expression. Wound Repair Regen (2006 Mar-Apr) 14(2):179-86 Favata M, Beredjiklian PK, Zgonis MH, Beason DP, Crombleholme TM, Jawad AF Soslowsky LJ . Regenerative properties of fetal sheep tendon are not adversely affected by transplantation into an adult environment. J Orthop Res (2006 Nov) 24(11):2124-32 Gausepohl T, Mader K, Pennig D. Mechanical distraction for the treatment of posttraumatic stiffness of the elbow in children and adolescents. J Bone Joint Surg Am (2006 May) 88(5):1011-21 Lambertz D, Mora I, Grosset JF, Perot C. Evaluation of musculotendinous stiffness in prepubertal children and adults, taking into account muscle activity. J Appl Physiol (2003 Jul) 95(1):64-72

47 48 49 RAPID RECOVERY & NERVE INJURY: AN OXYMORON? Rapid Recovery – The Fast Track American Association for Hand Surgery January 10, 2007

Christine B. Novak, PT, MSc, PhD(c) University Health Network, Toronto, Ontario References

1. Anastakis DJ, Chen R, Davis KD, Mikulis D. Cortical plasticity following upper extremity injury and reconstruction. Clin Plast Surg 2005; 32:617-634. 2. Bach-y-Rita P. Central nervous system lesions: sprouting and unmasking in rehabilitation. Arch Phys Med Rehab 1981; 62:413-417. 3. Bach-y-Rita P. Brain plasticity as a basis for recovery of function in humans. Neuropsychologia 1990; 28:547-554. 4. Chalidapong P, Sananpanick K, Klaphajone J. Electromyographic comparison of various exercises to improve elbow flexion following intercostal nerve transfer. J Bone Joint Surg 2006; 88B:620-622. 5. Chen R, Anastakis DJ, Haywood CT, Mikulis DJ, Manktelow RT. Plasticity of the human motor system following muscle reconstruction: a magnetic stimulation and functional magnetic resonance imaging study. 2003; 114:2434-2446. 6. Cusick CG, Wall JT, Whiting Jr. JH, Wiley RG. Temporal progression of cortical reorganization following nerve injury. Brain Res 1990; 537:355-358. 7. Dellon AL, Curtis RM, Edgerton MT. Reeducation of sensation in the hand after nerve injury and repair. Plast Reconstr Surg 1974; 53:297-305. 8. Florence SL, Boydston LA, Hackett TA, Taub Lachoff H, Strata F, Niblock MM. Sensory enrichment after peripheral nerve injury restores cortical, not thalamic, receptive field organization. Eur J Neurosci 2001; 13:1775-1766. 9. Lundborg G. Brain plasticity and hand surgery: an overview. J Hand Surg 2000; 25B:242-252. 10. Lundborg G. Nerve Injury and Repair. Churchill Livingstone; 2005. 11. Mackinnon SE, Novak CB. Nerve Transfers. Hand Clin 1999; 15:643-666. 12. Malessy MJ, Bakker D, Dekker AJ et al. Functional magnetic resonance imaging and control over the biceps muscle after intercostal - musculocutaneous nerve transfer. J Neurosurg 2003; 98:261-268. 13. Malessy MJ, Thomeer RT, van Dijk JG. Changing central nervous system control following intercostal nerve transfer. J Neurosurg 1998; 89:568-574. 14. Mandruch M, Bezuhly M, Anastakis DJ et al. Serial fMRI of adaptive changes in primary sensorimotor cortex following thumb reconstruction. 2002; 59:1278-1281. 15. Mano Y, Chuma T, Watanabe I. Cortical reorganization in training. J Electromyogr Kines 2003; 13:57-62. 16. Novak CB, Mackinnon SE. Treatment of a proximal accessory nerve injury with a nerve transfer. Laryngoscope 2004; 114:1482-1484. 17. Novak CB, Tung TH, Mackinnon SE. Patient outcome following a thoracodorsal to musculocutaneous nerve transfer for reconstruction of elbow flexion. Br J Plast Surg 2003; 55:416-419. 18. Pascual-Leone A, Cammarota A et al. Modulation of motor cortical outputs to the reading hand of braille readers. Ann Neurol 1993; 34:33-77. 19. Pascual-Leone A, Torres F. Plasticity of the sensorimotor cortex representation of the reading finger in Braille readers. Brain 1993; 116 (Pt 1):39-52. 20. Tung TH, Novak CB, Mackinnon SE. Nerve transfers to the biceps and brachialis branches to improve elbow flexion strength after brachial plexus injuries. J Neurosurg 2003; 98:313-318.

50 AAHS DAY-AT-A-GLANCE Thursday, January 11, 2007

6:30am - 4:00pm Speaker Ready Room San Cristobal

6:30am - 7:30am Financial Instructional Course 101 Cost-Effective and Tax-Efficient Managed Money for Physicians Rio Mar 1

7:00am - 4:00pm Meeting Services Rio Mar Atrium

7:00am - 8:00am Continental Breakfast with Exhibitors Rio Mar Foyer & Ocean Terrace

7:30am - 8:30am Instructional Courses 102 Treatment of Basal Joint Arthritis: More than Just Trapeziectomy Rio Mar 1 103 Treating Scapholunate Instability: A Gap Can Get You into Trouble Rio Mar 2 104 Emerging Concepts in the Treatment of Common Tendonopathies Rio Mar 3 105 Solving the Failed Carpal/Cupital Tunnel Decompression Rio Mar 4 106 Improving the Outcome of Flexor Tendon Repair Rio Mar 7 107 I Read it in The Journal. Should I Change My Practice? Rio Mar 8

8:30am - 8:45am President/Program Chair Welcome HAND Editor ASSH Presidential Welcome Rio Mar 6

8:45am - 9:45am Throwing Darts on the Back Nine: What Every Hand Surgeon Should Know about Evolution & the Skilled Human Hand Rio Mar 6

9:45am - 10:15am Wrist & Hand Joint Replacement: A Prosthetic Update Rio Mar 6

10:15am - 10:25am Presentation of 2006 Vargas Trip to Romania Rio Mar 6

10:25am - 10:55am Break with Exhibitors Rio Mar Foyer

10:55am - 12:15pm Concurrent Scientific Paper Session 1A Rio Mar 6

10:55am - 12:15pm Concurrent Scientific Paper Session 1B Caribbean 2 & 3

12:15pm - 1:00pm Keynote Speaker: Bob Jamieson Rio Mar 6

1:00pm - 1:30pm Lunch with Exhibitors Rio Mar Foyer & Ocean Terrace

1:00pm - 2:00pm Hand Journal Editorial Board Luncheon Egret

1:30pm - 2:30pm Instructional Courses 108 Advances In Extensor Tendon Repair and Rehabilitation: From Mallets to Motion Rio Mar 1 109 Distal Radius Malunion: Prevention And Correction Rio Mar 2 110 Wide Awake Approach To Hand Surgery Rio Mar 3 111 Reconstruction Of The Burned Hand In Adults and Children Rio Mar 4 112 Surviving And Salvaging PIPJ Injuries Rio Mar 7 113 Ulnar Wrist Pain: Understanding the Snaps, Clicks & Clunks Rio Mar 8

2:40pm - 3:40pm Coding Alerts to Maximize the Work Unit Value Rio Mar 6

51 107 I Read It In The Journal. Should I AAHS Change My Practice? Thursday, January 11, 2007 How do we use principles of critical reasoning and ev- dence-based practice to make clinical decisions? Can you believe what you read in the journal? Those of us 6:30am – 7:30am Financial Instructional Course in clinical practice can be overwhelmed by the deluge of information on treatment options for a variety of hand 101 Cost-Effective and Tax-Efficient Managed and upper extremity conditions and overwhelmed by the Money for Physicians literature. This panel will present methods to assist in Physicians are busy individuals that require specialized treatment choices based upon contemporary peer services for their wealth management needs. This discussion will focus on managed money for reviewed literature. Join a hand surgeon, hand physicians—the most cost-effective and tax-efficient therapist, physical therapist/epidemiologist and statisti- way to manage money for high income earning cian in a lively morning discussion. individuals. We will discuss current investment Susan Michlovitz, PT, PhD, CHT, Moderator opportunities and markets, maximizing the use of Scott Kozin, MD tax-free investments, as well as how to select the right Joy MacDermid, PhD, PT investment consultants that specialize in managing Paul Velleman, PhD money for healthcare professionals like you, who 8:30am – 8:40am President/Program Chair Welcome understand you and your family’s needs best. Patrick Donnelly, Smith Barney Consulting Group Jeff Palmer, Smith Barney Consulting Group

7:00am – 8:00am Continental Breakfast with Exhibitors Ronald Palmer, MD, AAHS President

7:30am – 8:30am Instructional Courses

102 The Treatment of Basal Joint Arthritis: More than Just Trapeziectomy A. Lee Osterman, MD, AAHS Program Chair Optimal functional outcome following surgical treatment of arthritis at the thumb basal joint must consider normal bio-mechanics and ligamental anatomy. This course will address the various Jorge L. Orbay, MD, AAHS Program Co-Chair options, beyond simple trapeziectomy, and empha- size pearls and pitfalls accompanying each. Elvim Zook, MD, Editor of HAND Matthew M. Tomaino, MD, Moderator Alejandro Badia, MD 8:40am – 8:45am ASSH Presidential Welcome Randall W. Culp, MD David M. Lichtman, MD Eduardo Zancolli. III, MD

8:45am – 9:45am Throwing Darts on the Back Nine: 103 Treating Scapholunate Instability: A Gap What Every Hand Surgeon Should Know about Can Get You into Trouble Evolution and the Skilled Human Hand This course will update the approach to treating this Hand surgeon Amy Ladd, anthropologist Mary Marzke, common and difficult carpal instability including and neurologist Frank Wilson offer a Darwinian perspec- surgical and therapy alternatives. tive on the management of complex hand disorders. Mel Rossenwasser, MD, Moderator Amy Ladd, MD William Geissler, MD Mary Marzke, Phd Frank Wilson, MD 104 Emerging Concepts in the Treatment of Mary Marzke, Phd, Professor of Anthropology at Common Tendonopathies Arizona State University, received her AB (1959) and This course offers practical pearls to patient manage- Ph.D. (1964) from the University of California Berkeley, ment of the common tendonopathies from the and her M.A. from Columbia University (1961). Her elbow to the hand. research focuses on the evolution of the human hand Wyndell Merritt, MD, Moderator and bipedality. Julianne Howell, PT MS CHT Nash Naam, MD Frank R. Wilson is retired clinical professor of neurolo- gy at Stanford University Medical Center, and a co- 105 Solving the Failed Carpal/Cubital founder and former medical director of the Peter Tunnel Decompression F. Ostwald Health Program for Performing Artists at the This instructional course will address the challenging University of California School of Medicine, San problem of evaluation and management of the Francisco. He is a graduate of Columbia College in New patient with problems following failed carpal and York City and the University of California School of cubital tunnel surgery. Key points in the physical Medicine in San Francisco and is the author of The Hand: examination and surgical technique of “redo How Its Use Shapes the Brain, Language, and Human “surgery will be emphasized. Culture, nominated for a Pulitzer Prize for nonfic- Susan Mackinnon, MD, Moderator tion in 1998. Christine Novak, PT MS Dean Sotereanos, MD John Taras, MD 9:45am – 10:15am Wrist and Hand Joint Replacement: A Prosthetic Update 106 Improving the Outcome of Flexor Tendon Repair Building on the lessons learned from the creative and This session will examine both traditional methods as forward thinking of the first endoprosthetic developers, well as focusing on new developments in flexor today’s implants for the wrist and hand have seen tendon repair, reconstruction, and rehabilitation with significant improvements in design, longevity, durability the goal of optimizing functional outcomes. and ease of implantation. This lecture will provide a Nicholas Vedder, MD, Moderator overview of the “state of the art” of endoprosthetic Peter Amadio, MD treatment of wrist and hand arthritis with a historical Randipsingh Bindra, MD perspective. Michael Neumeister, MD Richard A. Berger, MD, PhD

52 10:15am – 10:25am Presentation of 2006 Vargas Trip to Romania 11:45am - 11:50am Donna Pendleton, MS, PT, CHT Dupuytren’s Diathesis Revisited- Modification of an Important Prognostic Lorna Ramos, MA, OTR Indicator Institution where the work was prepared: University of Manchester, Manchester, 10:25am – 10:55pm Break with Exhibitors United Kingdom Sandip Hindocha, MBChB; John K. Stanley, MCh, Orth, FRCS; Stewart J. Watson, 10:55am - 12:15pm CONCURRENT SCIENTIFIC MRCP, FRCS; Ardeshir Bayat, MD, PhD PAPER SESSION 1A 11:50am - 11:55am *Designates resident/fellow paper presentations Safety and Efficacy of Injectable Mixed Collagenase Subtypes in the Treatment of Dupuytren’s Disease, Early Phase III Results Moderators: Brian Adams, MD Institution where the work was prepared: Auxilium Pharmaceuticals, Inc, Malvern, Christine Novak, PT, MS PA, USA Marie Badalamente, PhD; Lawrence Hurst, MD 10:55am - 11:00am In-vivo 3-D Distal Radioulnar Joint Arthrokinematic Analysis During Resisted 11:55am - 12:00pm Active Pronation and Supination Discussion Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA kazunari Tomita, MD; Shian Chao Tay, MBBS, FRCS, FAMS; Richard A. Berger, MD, 10:55am - 12:15pm CONCURRENT SCIENTIFIC PhD; Kimberlyamrami; Kai-Nan An, PhD PAPER SESSION 1B *Designates resident/fellow paper presentations

11:00am - 11:05am Moderators: Peter Amadio, MD The Effect of Wide Excision of the Distal Ulna on Radioulnar Load-Sharing Julianne Howell, PT, MS, CHT Institution where the work was prepared: Wayne State University, Department of Orthopaedic Surgery, Detroit, MI, USA Gregory L. DeSilva, MD; Joseph Horton, MD; Christina Huber, MS 10:55am - 11:00am *The Effect of IL-10 Overexpression on the Biomechanical and Histological Properties of Healing Tendon 11:05am - 11:10am Institution where the work was prepared: University of Pennsylvania, Philadelphia, The Distal Radio Ulna Joint Prosthesis as an Effective Last Resort after Failed PA, USA Salvage Procedure; a Study of Functional Outcomes in 18 Cases Sudheer Reddy, MD; Eric T. Ricchetti; Miltiadis H. Zgonis; Heather L. Ansorge; Institution where the work was prepared: cmki, louisville, KY, USA Kenneth W. Liechty, MD; Louis J. Soslowsky, PhD; Pedro K. Beredjiklian, MD Adam Goodwin; luis laurentin 11:00am - 11:05am 11:10am - 11:15am Flexor Tendon Repair Using a Novel Polylactide/Polyglycolide Platform: *The “Fovea” Sign for Defining Ulnar Wrist Pain: An Analysis of Sensitivity Biomechanical & Immunohistochemical Analyses and Specificity Institution where the work was prepared: Stanford University, Palo Alto, CA, USA Institution where the work was prepared: Mayo Clinic College of Medicine, Timothy R. McAdams, MD; Vincent R. Hentz, MD; James Chang, MD Rochester, MN, USA Shian Chao Tay, MD; Kazunari Tomita, MD; Richard A. Berger, MD, PhD 11:05am - 11:10am *Evaluation of Looped Suture and New Suture Material for Tendon Repair 11:15am - 11:20am Institution where the work was prepared: Loma Linda University, Loma Linda, CA, Failed Darrach Procedure: an Allograft Solution USA Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, Lawrence G. Sullivan, MD; Chad Brockardt; Montri D. Wongworawat, MD; Qiang PA, USA Dai, PhD; Barry Watkins, MD Filippos S. Giannoulis; Jeffrey A. Greenberg, MD; Rob W. Weiser, PA-C; Dean G. Sotereanos 11:10am - 11:15am *Biomechanical Analysis of a New Ultrasound Welded Knotless Tendon 11:20am - 11:25am Repair Discussion Institution where the work was prepared: University College Hospital,, Galway, Ireland Moderators: Scott Kozin, MD Colin L. Riordan, MB, BCh, MRCS; Jeff Chan; Jack L Kelly; Padraic J Regan Susan Michlovitz, PT, PhD, CHT 11:15am - 11:20am 11:25am - 11:30am Discussion *Biomechanical Evaluation of Volar Locking Plates for Distal Radius Fractures Institution where the work was prepared: Stony Brook University, Stony Brook, NY, USA 11:20am - 11:25am Scott Michael Levin, MD; Glenn Alan Teplitz, MD; Cory Oliver Nelson; Jonathon Management of the Central Extensor Tendon on the Surgical Approach for Devlin Botts; Yong Kwon; Frederick James Serra-Hsu Exposure of the Proximal Interphalangeal Joint: A Biomechanical Study Institution where the work was prepared: University of New Mexico, Albuquerque, 11:30am - 11:35am NM, USA *Biomechanical Comparison of Different Volar Fracture Fixation Plates for Keikhosrow Firoozbakhsh; Deana Mercer; Alex Carvalho; Moheb S. Moneim Distal Radius Fractures Institution where the work was prepared: University of Colorado Health Sciences Center, Denver, CO, USA 11:25am - 11:30am Kareem Sobky, MD; Kenneth Thomas, MD; Todd Baldini; Joel Bach; Jennifer Did We Find a New Method in Solving the Mallet Finger Deformity? Moriatis Wolf, MD Institution where the work was prepared: University of Medicine “Iuliu Hatieganu”, Cluj-Napoca, Romania 11:35am - 11:40am Alexandru Georgescu, Prof, MD, PhD; Irina Capota; Ileana Matei; Filip Ardelean Why Plate? Fractures of the Distal Radius: A Unique Approach Institution where the work was prepared: M Ather Mirza MD PC, Smithtown, NY, USA 11:30am - 11:35am M. Ather Mirza, MD; Mary Kate Reinhart, CNP Results of Tenodermodesis for Severe Chronic Mallet Finger Deformity in Children 11:40am - 11:45am Institution where the work was prepared: Children’s Hospital, Boston, MA, USA Discussion Tarik Kardestuncer, MD; Donald S. Bae, MD; Peter M. Waters, MD

53 11:35am - 11:40am Jamieson has also reported extensively from the *Thumb Extension Is Immediate following Extensor Indicis Proprius to Middle East beginning with the 1973 Yom Kippur war Extensor Pollicis Longus Tendon Transfer Using the “Wide Awake” Approach and subsequently the 1982 conflict in Lebanon, from Institution where the work was prepared: Saint John Regional Hospital, Saint Iran, Syria, Jordan and Saudi Arabia and Baghdad. John, NB, Canada Beginning in 1971, he was assigned first as national correspondent in the Chicago bureau, then White Michael Bezuhly, BSc, MD; Gerald Sparkes; Amanda Higgins; Michael Neumeister; House correspondent from 1975 to 1978, then to Donald H. Lalonde assignments in London and as a senior national correspondent based in New York. 11:40am - 11:45am 1:00pm – 1:30pm Lunch with Exhibitors Discussion 1:00pm - 2:00pm Hand Journal Editorial Board Luncheon Moderators: Pedro Beredjiklian 1:30pm – 2:30pm Instructional Courses Aviva Wolff, BSC, OTR/L, CHT 108 Advances In Extensor Tendon Repair And 11:45am - 11:50am Rehabilitation: From Mallets To Motion This course will offer an up to date review of the Single Incision Repair with Suture Anchors for Treatment of Distal Biceps current state of the art of extensor tendon repair and Tendon Rupture: a 59 Cases Follow up rehabilitation from the distal terminal tendon inser- Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, tion to the proximal forearm. The participants will PA, USA hear which injuries are best treated surgically, and Filippos S. Giannoulis, MD; Rob W. Weiser; Dean G. Sotereanos which are best treated with splinting, casting or observation. 11:50am - 11:55am John D. Lubahn, MD, Moderator Immediate Motion After Distal Biceps Repair Using a Dynamic Elbow Flexion- Stephanie Sweet, MD Assist Splint: Therapy Progression and Outcomes 109 Distal Radius Malunion: Prevention Institution where the work was prepared: Samaritan Hand Therapy Specialists, And Correction Corvallis, OR, USA Malunion of the distal radius fracture is still one of the Julianne Howell, MS, PT, CHT; James Gyovai, PT, CHT; Luis Vela, DO most common complications and one of the most common sources of legal action. These experts will address how to avoid the complication and, as 11:55am - 12:00pm importantly, how to restore radial anatomy. *Giant Cell Tumor of the Tendon Sheath: Risk Factors for Recurrence Jorge L. Orbay, MD, Moderator Institution where the work was prepared: Mount Carmel Medical Center, David Bozentka, MD Columbus, OH, USA 110 Wide Awake Approach To Hand Surgery John G. Mowbray, MD; Raymond K. Wurapa, MD; John M. Bednar, MD; Brent A. This course will provide the necessary information to Bickel; Damon C. Adamany allow the hand surgeon to perform most hand opera- tions under pure local anesthesia without sedation and 12:00pm - 12:05pm without a tourniquet. The wide awake pain free *Recurrent Giant Cell Tumors of the Hand; a Prospective Study patient is able to actively move the reconstructed Institution where the work was prepared: Henry Ford Health System, Detroit, MI, structures which the surgeon can observe and adjust before the skin is closed. The 4th dimension of active USA movement by the patient is added to the surgery. Craig Oser, DO; Aamir Siddiqui, MD; Joseph Musial, PhD; Peter Janevski, MD Donald H. Lalonde, MD, Moderator N. Bradly Meland, MD 12:05pm - 12:10pm 111 Reconstruction of the Burned Hand in Adults *Syndactyly Correction in Patients with Associated Syndromes and Children Institution where the work was prepared: The Johns Hopkins School of Medicine, Reconstruction of the burned hand in adults and Baltimore, MD, USA children is presented through discussion and exam- William Dahl, BA; E. Gene Deune, MD ples of acute and reconstructive principles. Planning reconstructive procedures requires thorough knowl- edge of contraction and maturation as well 12:10pm - 12:15pm as surgical technique. This instructional course will Discussion provide insight into timing of surgical reconstruction and prognosis of return of maximum hand function. 12:15pm – 1:00pm Keynote Speaker: Bob Jamieson Roger Simpson, MD, Moderator Bruce Brewer, MD Anthony Smith, MD 112 Surviving and Salvaging PIPJ Injuries This course will review the latest information on con- strained and nonconstrained arthroplasty and on Covering Medicine, Wars and Politics arthrodesis for irreparable PIPJ injuries and post A Native of Illinois, Jamieson served in the U.S. Navy traumatic arthritis. and attended Knox College from which he received Alan Freeland, MD, Moderator an honorary doctor of letters degree in 1996. Robert Beckenbaugh, MD The address will focus on ABC's unique way of cov- Mark R. Belsky, MD ering medicine, how we have been covering the 113 Ulnar Wrist Pain: Understanding the Snaps, middle east and the issues that will impact every day Clicks & Clunks life in the United States as well as the political This course will discuss the common causes of ulnar landscape that will affect us all. Questions will sided wrist pain, correlating the physical findings also be taken at the end of the address. including snaps, clunks, and pops with the patholog- ic anatomy. The treatment for these common ulnar Bob Jamieson joined ABC News in 1990 as a corre- sided conditions will be discussed including splinting, spondent based in New York. During more than 30 non operative modalities and surgical solutions. years as a network television news correspondent, John M. Bednar, MD, Moderator Jamieson has reported from all seven continents, won Scott G. Edwards, MD five National News Emmys and was cited for his Mark Rekant, MD coverage of 9/11 as part of the ABC News team Teri Skirven, OTR/L, CHT honored with both Alfred I. DuPont and George Foster 2:40pm – 3:40pm Coding Alerts to Maximize the Work Unit Value Peabody Awards. His assignments with ABC News The course will provide the insight into the RBRVS have varied widely, from the Kurdish refugee crisis in and coding updates, tips and pearls. Northern Iraq after the first Gulf War to 9/11. Daniel Nagle, MD

54 AAHS DAY-AT-A-GLANCE Friday, January 12, 2007

6:30am - 5:00pm Speaker Ready Room San Cristobol

6:30am - 7:30am Instructional Course for Non-Members 114 Financial Planning for the Newly Established Surgeon Rio Mar 1

7:00am - 7:30am Annual Business Meeting Breakfast (AAHS members only) Rio Mar 8

7:30am - 8:30am Instructional Courses 115 Resurrection of Dead Bone: Solving Kienboch’s & Avascular Non-Unions Rio Mar 1 116 Pediatric Brachial Plexus Injury Rio Mar 2 117 Adult Elbow Fractures Rio Mar 3 118 New Concepts in Total Wrist Replacement Rio Mar 4 119 Innovations in Scaphoid Care Rio Mar 9 120 Post Traumatic Hand Reconstruction Rio Mar 10

8:35am - 9:20am Panel: Problem Solving in Distal Radius Fracture Rio Mar 6

9:00am - 6:00pm Meeting Services Rio Mar Atrium

9:00am - 11:00am ASRM Strategic Planning Session Rio Mar 7

9:20am - 9:50am Presidential Address Rio Mar 6

9:50am - 10:25am J. Joseph Danyo Presidential Invited Lecturer: Robert D. Beckenbaugh, MD Rio Mar 6

10:25am - 10:55am Break with Exhibitors Rio Mar Foyer

10:55am - 12:30pm Concurrent Scientific Paper Session 2A Rio Mar 6

10:55am - 12:30pm Concurrent Scientific Paper Session 2B Caribbean 2 & 3

11:00am - 1:00pm ASRM Council Meeting Rio Mar 7

12:30pm - 1:00pm Hand Federacion Presentation: Contributions & Influences of Argentina to Hand Surgery Rio Mar 6

1:00pm - 6:15pm Comprehensive Hand Surgery Review Course Rio Mar 6

2:00pm - 3:00pm AAHS Board of Directors Meeting Boardroom

3:00pm - 5:30pm ASPN Council Meeting Rio Mar 7

6:00pm - 7:30pm AAHS Invited Speaker: Richard Kogan, MD Rio Mar 1-3

7:30pm - 11:00pm AAHS Reception & Awards Dinner Dance Caribbean Terrace & Ballroom

55 8:35am – 9:20am Panel: Problem Solving in Distal Radius AAHS Fracture Friday, January 12, 2007 Jaiyoung Ryu, MD Moderator William Geissler, MD Amy Ladd, MD 6:30am – 7:30am Financial Instructional Course Jorge L. Orbay, MD for Non-Members 9:00am – 11:00am ASRM Strategic Planning Session 114 Financial Planning for the Newly 9:20am – 9:50am Presidential Address Established Surgeon If you are like most busy physicians, you may lack the time needed to select the right investment consultants that best meet your specific financial needs. On the other hand, selecting the right team of investment consultants is one of the most Ronald Palmer, MD important decisions you can make—one that can have an enormous impact on your long-term 9:50am – 10:25am J. Joseph Danyo Presidential Invited Lecturer: financial goals. This discussion will focus on Robert D. Beckenbaugh, MD the basic things residents or new physicians need to do in order to begin investing for themselves and their practices, and how to select the right investment consultants. Patrick Donnelly, Smith Barney Consulting Group “Is It Fun Anymore?” Jeff Palmer, Smith Barney Consulting Group Medical practice has changed drastically over the last thirty years. We have seen conversion of patient 7:00am – 7:30am Annual Business Meeting Breakfast oriented caring medical treatment to business (attendence is limited to AAHS members only) oriented money making, cost saving approaches to patient care. Questions arise with regard to the ethics 7:30am – 8:30am Instructional Courses and morality of such changes. Is there room to 115 Resurrection of Dead Bone: Solving Kienboch’s provide expert care and have fun as a physician and Avascular Non-Unions anymore in caring for the, injured, ill or especially the This instructional course will discuss the daignosis, profitless elderly? The answer may lie in our original classification and treatment options for scaphoid reasons for going into medicine and the oath which delayed union/nonunion with AVN, Preiser’s disease, we have all taken. Kienbock’s, as well as capitate AVN. Heavy emphasis Robert Beckenbaugh, MD is Professor of Orthopedic will be placed on the newer armamentarium of VBG’s Surgery at the Mayo Clinic Rochester. His research (vascularized bone graft) and their selective use for each interests include continuing work on the develop- of these difficult diagnostic categories. ment of artificial joint replacements for the wrist and T. Greg Sommerkamp, MD, Moderator hand. He served as president of the AAHS from 1992-3. Kyle Bickel, MD, FACS 10:25am – 10:55am Break with Exhibitors Steven L. Moran, MD 116 Pediatric Brachial Plexus Injury 10:55am - 12:30pm CONCURRENT SCIENTIFIC Discuss the management of pediatric brachial plexus PAPER SESSION 2A injuries from diagnosis through treatment. Review operative indications for primary microsurgery and *Designates resident/fellow paper presentations secondary reconstruction. Review surgical techniques, outcomes, and complications. Moderators: Kevin Chung, MD Scott Kozin, MD, Moderator Susan Mackinnon, MD Allan J. Belzberg, MD Howard M. Clarke, MD 10:55am - 11:00am The Cause of Carpal Tunnel Syndrome? 117 Adult Elbow Fractures Elbow fractures are unforgiving. These experts will Institution where the work was prepared: University of Louisville, School of Public address the assessment, operative tactics, and compli- Health and Informatio, Louisville, KY, USA cations associated with elbow fractures Steven J. McCabe, MD, MSc; Vasyl Pihur; Roberto S. Rosales, MD, PhD; Isam Mark Baratz, MD Atroshi, MD, PhD Michael R. Hausman, MD David Ring, MD 11:00am - 11:05am Comparison of Psychosocial Profile of Patients with Neuropathic Conditions 118 New Concepts in Total Wrist Replacement This Instructional Course will provide updated Treated with and without Surgery information on new, precision guided replacement of Institution where the work was prepared: Hand and Microsurgery Center of El the wrist. Presentations will include the current state Paso, El Paso, TX, USA of the art in Total Wrist Replacement with alterna- Jose Monsivais, MD; Kris Robinson, PhD, FNP tive procedures described along with initial results of treatment for both rheumatoid and posttraumatic 11:05am - 11:10am arthritis of the wrist. *A Detailed Cost and Efficiency Analysis of Performing Carpal Tunnel Surgery William Cooney, III, MD, Moderator in the Main Operating Room Versus the ambulatory Setting Brian Adams, MD Institution where the work was prepared: Dalhousie University / Saint John Luis Scheker, MD Regional Hospital, Saint John, NB, Canada 119 Innovations in Scaphoid Care Martin R. LeBlanc, BSc, MD; Janice Lalonde, RN; Donald H. Lalonde, BSc, MSc, MD The faculty will review their reconstructive approach to mutilating hand injuries, including general 11:10am - 11:15am princibles, timing and latest techniques in skeletal and soft tissue reconstructions. Pronator Syndrome: A Cadaveric Study of the True Sites of Compression Alexander Shin, MD Institution where the work was prepared: Southern Illinois University School of Joseph Slade, III, MD Medicine, Springfield, IL, USA Damon Cooney, MD, PhD; Reuben Bueno; Michael W Neumeister 120 Post Traumatic Hand Reconstruction The faculty will review their reconstructive approach 11:15am - 11:20am to mutilating hand injuries, including general principles, timing and latest techniques in skeletal Outcome Study of Vascularized Ulnar Nerve Transposition in 100 Consecutive and soft tissue reconstructions. Patients with Cubital Tunnel Syndrome W.P. Andrew Lee, MD, Moderator Institution where the work was prepared: Temple University Hospital, Philadelphia, Richard E. Brown, MD PA, USA Alexandru Georgescu, MD Julie Spears;amit Mitra; Beth Mccampbell; Ravi Kiran; John Roussalis; Eva Chavez; L. Scott Levin, MD, FACS Avir Mitra

56 11:20am - 11:25am 12:25pm - 12:30pm Discussion Discussion

Moderators: Keith Brandt, MD 10:55am - 12:30pm CONCURRENT SCIENTIFIC John Taras, MD PAPER SESSION 2B *Designates resident/fellow paper presentations 11:30am - 11:35am Diagnosis for Hand-Arm Vibration Syndrome 10:55am - 11:30pm Institution where the work was prepared: Medical College of Wisconsin, Moderators: Peter Murray, MD Milwaukee, WI, USA Nash Naam, MD Dennis Kao; ji-Geng Yan, MD; Hani S. Matloub; Lin-LIng Zhang; James R. Sanger; Yuhui Yan; Danny A. Riley; Michael Agrestic; David Rowe; Paula Galaviz; Judith 10:55am - 11:00am Marechant-Hanson; Scott Lifchez *Effects of the Deep Anterior Oblique and Dorsoradial Ligaments on Trapeziometacarpal Joint Stability 11:35am - 11:40am Institution where the work was prepared: The University of Chicago, Chicago, IL, USA Neurochemical Response in Forelimb Tendons in a Rat Model of Upper Matthew Colman, BA; Daniel Paul Mass; Louis Draganich Extremity WMSD 11:00am - 11:05am Institution where the work was prepared: Temple University, Philadelphia, PA, USA LRTI Carpometacarpal Joint Arthroplasty With Flexor Carpi Radialis Sparing Jane M. Fedorczyk, MS, PT, CHT; Ann E. Barr, DPT, PhD; Mamtaamin; Marcus J. Allograft: A Review of 30 Cases Handy; Mary F. Barbe, PhD Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA 11:40am - 11:45am Dean G. Sotereanos; Filippos S. Giannoulis; Rob W. Weiser Comparison of Return to Work: Endoscopic Cubital Tunnel Release versus Anterior Subcutaneous Transposition of the Ulnar Nerve 11:05am - 11:10am Institution where the work was prepared: Orthopaedic Specialists, Davenport, IA, USA Arthroscopic Cuetis Interpositional Arthroplasty of The BasilarJointof The Thumb TYSON Cobb, MD; Patrick T Sterbank, PA-C Institution where the work was prepared: Kaiser Permanente, Bakersfield, CA, USA Albert R. Swafford, MD 11:45am - 11:50am Peripheral Nerve Injuries and Nerve grafting 11:10am - 11:15am Institution where the work was prepared: Boston University School of Medicine, Long Term Outcome of Thumb Trapeziometacarpal Arthrodesis: A Review of Boston, MA, USA 178 Cases Harilaos Theodore Sakellarides, MD Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Marco Rizzo, MD; Steven L. Moran, MD; Alexander Y. Shin

11:50am - 11:55am Humeral Shaft Fractures and Radial Nerve Palsy: To Explore or Not to Explore. 11:15am - 11:20am . . That is the Question? A New Frontier: Total Joint Arthroplasty for the Treatment of PIP Joint Institution where the work was prepared: Grandview Medical Center, Dayton, OH, Arthrosis USA Institution where the work was prepared: The Permanente Medical Group, Matthew Heckler, DO; HB Bamberger Sacramento, CA, USA Robert R. Slater, MD, FACS

11:55am - 12:00pm 11:20am - 11:25am Iatrogenic Injury to the Deep Motor Branch of the Ulnar Nerve in Percutaneous Discussion Pinning of 5th Carpometacarpal Fracture Dislocations : A Cadaveric Study Institution where the work was prepared: Albert Einstein Medical Center, Philadelphia, PA, USA Moderators: Kevin Plancher, MD Minn Saing, MD; James Raphael Dean Soteareanos, MD

12:00pm - 12:05pm 11:25am - 11:30am Discussion The Dorsal/Volar Method Improves Reliability in Measuring Wrist Range of Motion: An In Vitro Study of Reliability and Accuracy of Manual Goniometry Moderators: Allen van Beek, MD Institution where the work was prepared: Hospital for Special Surgery, New York, Nick Vedder, MD NY, USA Aviva L. Wolff, BS, OTR, CHT; Timothy I. Carter, BA; Brian Pansy, BS; Howard J. 12:05pm - 12:10pm Hillstrom, PhD; Sherri I. Backus-Saccoliti, DPT; Mark W. Lenhoff, BS; Scott W. *Outcomes in Upper Extremity Replantation: a National Study of 16,128 Wolfe, MD Replants Institution where the work was prepared: Yale University, New Haven, CT, USA 11:30am - 11:35am Michael Chen, MD Nerve Ending Distribution in Human Radiocarpal Ligaments: a Fluorescent Immunohistochemical Study Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA 12:10pm - 12:15pm Kazunari Tomita, MD; Richard A. Berger, MD, PhD; Evelyn Berger; Kai-Nan An, Traumatic Thumb Reconstruction by Index Pollicization PhD; Jirachart Kraisarin, MD Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Cesar J. Bravo, MD; Alexander Shin, MD; Allen T. Bishop, MD; Steven Moran 11:35am - 11:40am Preliminary Results after Reconstruction of the Destroyed DRUJ with an Ulnar 12:15pm - 12:20pm Head Endoprosthesis The Free Style Concept in Harvesting Transpozition Island Perforator Flaps in Institution where the work was prepared: Dep. of Hand, Plastic & Reconstructive the Forearm Surgery -BG Trauma Center, Ludwigshafen, Germany Institution where the work was prepared: University of Medicine “Iuliu Hatieganu”, Michael Sauerbier, MD, PhD; Miriam Müller, MD; Günter Germann, MD, PhD Cluj-Napoca, Romania Alexandru Georgescu, Prof, MD, PhD; Irina Capota; Ileana Matei; Filip Ardelean 11:40am - 11:45am Reconstruction of the TFCC using ECU Half-slip - a New Technique 12:20pm - 12:25pm Institution where the work was prepared: Department of Orthopaedic Surgery, Cryopreservation of Composite Tissue Transplants School of Medicine, Keio Univ, Tokyo, Japan Institution where the work was prepared: University of Kentucky, Lexington, KY, USA Toshiyasu Nakamura, MD, PhD; Hiroyasu Ikegami; Kazuki Sato; Noriaki Brian Rinker, MD; XD Cui; DY Gao; BF Fink; HC Vasconez Nakamichi; Noriko Okuyama; Shinichiro Takayama, MD, PhD

57 11:45am - 11:50am 1:15pm – 1:35pm Compressive Neuropathies & CRPS *Mechanical Testing of Distal Radioulnar Instability Repair: Ligament In this lecture carpal tunnel syndrome and cubital Reconstruction vs Capsulorraphy tunnel syndrome will be reviewed. Physical examina- Institution where the work was prepared: Leonard M. Miller School of Medicine, tion and diagnostic modalities will be emphasized. University of Miami, Miami, FL, USA The last portion of the presentation will review the Christopher J. Dy, BS, MD-Candidate; E. Anne Ouellette; Ali Malik; Veronica Diaz; diagnosis, treatment and long-term sequelae of Anna-Lena Makowski; Edward Milne; Andre Barreto; Loren Latta complex regional pain syndrome. Daniel Nagle, MD 11:50am - 11:55am 1:35pm – 2:00pm Thumb Basal Joint Arthritis, Wrist Arthritis, Discussion Kienbock’s Disease This lecture will address the fundamentals of diagno- Moderators: Richard E Brown, MD sis and treatment for thumb basal joint arthritis, Dan Nagle, MD SLAC/SNAC degeneration of the wrist, and avascular necrosis of the lunate. Critical success factors 12:00pm - 12:05pm necessary to obtain favorable outcomes will be *Does Thumb Immobilization Contribute to Scaphoid Fracture Stability? emphasized. Institution where the work was prepared: Loma Linda University, Loma Linda, CA, Matthew Tomaino, MD USA 2:00pm – 2:25pm Inflammatory Arthritis of the Hand and Wrist J. Mark Schramm, MD; Minhthy Nguyen, BA; Montri D. Wongworawat, MD; Ingrid Reconstructive options for deformities secondary to Kjellin, MD rheumatoid arthritis and other inflammatory condi- tions will be outlined. Indications and techniques for 12:05pm - 12:10pm MCP arthroplastied, tendon reconstruction, synovec- *Complications in Percutaneous Screw Fixation of Scaphoid Fractures tomy, wrist arthrodesis and total wrist arthroplasty Institution where the work was prepared: University of North Carolina Hospitals, with be reviewed. Chapel Hill, NC, USA Brian Adams, MD Brandon DuBose Bushnell, MD; Andrew McWilliams, MPH; Terry M. Messer, MD 2:25pm – 2:45pm Distal Radius Fractures A comprehensive review of adult distal radius frac- 12:10pm - 12:15pm tures including the clinical evaluation, diagnostic *The Use of Routine Radiography in the Evaluation of Ganglion Cysts of the imaging options and interpretation, indications for Wrist operative versus non-operative treatment and the Institution where the work was prepared: University of Michigan Hospital, Ann current strategies and indications for the various Arbor, MI, USA operative treatment techniques. Andrew S. Wong, MD; Peter J.L. Jebson; Peter M. Murray, MD; Stephen D. Trigg, Peter J. L. Jebson, MD MD 2:45pm – 2:55pm Distal Radioulnar Joint 12:15pm - 12:20pm Anatomy, biomechanics and patterns of injury will be *Arthroscopic Management of Dorsal Wrist Ganglions discussed. Bone and soft tissue salvage reconstruc- Institution where the work was prepared: UCSF, Division of Plastic Surgery, San tive options will be illustrated. Francisco, CA, USA Brian Adams, MD Amarjit S. Dosanjh; Scott L. Hansen, MD; Kyle Bickel, MD 2:55pm – 3:10pm Scaphoid Fractures and Non-Unions A review of the clinical features, diagnostic chal- 12:20pm - 12:25pm lenges, operative and non-operative treatment Discussion options, and a contemporary approach to the patient with an acute scaphoid fracture or established 11:00am – 1:00pm ASRM Council Meeting non-union. Peter J. L. Jebson, MD 12:30pm – 1:00pm Hand Federacion Presentation: 3:10pm – 3:30pm Carpal Instability Contributions and Influences of Argentina A review of the anatomy and mechanics of the wrist to Hand Surgery as it relates to carpal instability, including a review of History of Hand Surgery in Argentina beginning in the diagnostics and treatment of common patterns the early 50´s and presenting all the main contri- of instability. butions of Argentinian surgeons helping the Richard Berger, MD, PhD knowledge of our speciality. Eduardo Zancolli III, MD 3:30pm – 3:45pm Fractures of the Metacarpals and Phalanges Metacarpal and phalangeal fractures are among the 1:00pm – 6:15pm Comprehensive Hand Surgery Review Course most common injuries seen in the hand. A thorough Peter M. Murray, MD, Chairman review of the anatomy and biomechanics of these Randy Bindra, MD, Co-Chairman injuries will be provided. The treatment choices of The excellent faculty of this Comprehensive Hand closed management, percutaneous pinning, plate Surgery Review Course will address the important fixation and intramedullary rodding will be reviewed along with their technical nuances. topics covered on board examinations, the hand Stephen D. Trigg, MD surgery certification examination and resident in-training examinations. From arthrogryposis to 3:45pm – 4:00pm Flexor & Extensor Tendon Injuries Z-plasty, this course will truly have it all and you This presentation will review aspects of physical exam will consider it time well spent. and radiographic analysis of extension tendon injuries, Course is complimentary, but pre-registration is required. technical aspects and biomechanical data and post op Box lunch will be provided. rehab protocols. Basic science of tendon healing and repair will also be discussed. 1:00pm – 1:15pm Tendonopathies and Dupuytrens Contracture Kevin J. Renfree, MD Tendonopathies of the hand and wrist and 4:15pm – 4:30pm Infections of the Hand Dupuytrens Contracture are among the most Comprehensive review of infections of the hand with up to common problems seen in hand surgery. An date information to allow the participant to feel comfortable overview of the pathophysiology of these treating patients with their maladies and being able to conditions will be provided as well as specific successfully complete their questions on the Certificate of treatment recommendations. Added Qualifications exam. Peter M. Murray, MD Kevin D. Plancher, MD, MS, FACS, FAAOS

58 4:30pm – 4:55pm Congenital Hand Differences Discuss congenital anomalies of the upper extremity including embryology, diagnosis, and treatment. Focus on associated syndromes that require accurate diagnosis and management. Review surgical techniques, outcomes, and complications. Scott H. Kozin, MD

4:55pm – 5:15pm Tumors of the Hand and Wrist Discussion of the pathology, and treatment of benign and malignant bone and soft tissue tumors affecting the hand and wrist. Edward A. Athanasian, MD

5:15pm – 5:35pm Soft Tissue Coverage in the Hands A variety of pedicled flaps and free flaps of are available for coverage of the soft tissue defects of the hand. These flaps will be reviewed and technical tips provided. A spectrum of cases will be reviewed to illustrate the utility of each soft tissue coverage procedure. William C. Pederson, MD

5:35pm – 5:50pm Tendon Transfers for the Hand Palsy of the median, ulnar or radial nerves can be devastating to hand and wrist function. Tendon transfers can provide predictable restoration of digital function. The more commonly chosen tendon transfers will be discussed along with the technical challenges unique to each set of transfers. Randipsingh Bindra, MD

5:50pm – 6:05pm Vascular Disorders of the Hand/Reimplantation Vascular disorders of the hand are uncommon and the indications for reimplantation narrow. This presentation will discuss the various diagnostic challenges encountered in vascular disorders of the hand and techniques and indication for reimplanta- tion will be discussed. Peter M. Murray, MD

6:05pm – 6:15pm Questions/Adjourn

3:00pm – 5:30pm ASPN Council Meeting

6:00pm – 7:30pm AAHS Invited Speaker: Richard Kogan, MD

“Music and Medicine: George Gershwin” George Gershwin (1898-1937) was one of the greatest composers in American history, writing memorable songs and concert pieces until his untimely death at age 38 of a brain tumor. Concert pianist and physician Dr. Richard Kogan will discuss Gershwin’s life from a medical and psychiatric perspective and will perform Rhapsody in Blue and other examples of Gershwin’s glorious music. Richard Kogan has a distinguished career both as a concert pianist and as a psychiatrist. He has been praised for his “eloquent, compelling and exquisite playing” by the New York Times and the Boston Globe wrote that “Kogan has somehow managed to excel at the world’s two most demanding professions.” He has gained international renown for his groundbreak- ing work on the connections between music and healing and on the influence of medical and psychiatric illnesses on thecreative output of composers such as Mozart Beethoven, Schumann, Tchaikovsky, and Gershwin. His work forms the basis for the Yamaha DVD series entitled “Richard Kogan: Music and the Mind”. Dr. Kogan is a graduate of the Juilliard School of Music and of Harvard College and Harvard Medical School. He completed his psychiatry residency training at NYU. He currently has a private practice of psychiatry in New York City and is affiliated with the Weill - Cornell Medical School as Director of its Human Sexuality Program.

7:30pm - 11:00pm AAHS Reception & Awards Dinner Dance See page 16 for details

59 AAHS/ASRM/ASPN DAY-AT-A-GLANCE Saturday, January 13, 2007

6:00am - 5:00pm Speaker Ready Room San Cristobal

6:30am - 7:30am Continental Breakfast with Exhibitors Rio Mar 5 & Ocean Terrace

6:30am - 5:00pm Meeting Services Rio Mar Atrium

7:00am - 8:00am Panel: Upper Extremity Injuries in Modern Warfare Rio Mar 6

8:00am - 8:10am AAHS/ASRM/ASPN Presidents’ Welcome Rio Mar 6

8:10am - 9:10am AAHS/ASRM/ASPN Presidents’ Invited Lecture: Rio Mar 6 Richard H. Gelberman, MD

9:10am - 9:30am Break with Exhibitors Rio Mar 5

9:30am - 10:30am AAHS/ASRM/ASPN Outstanding Nerve Paper Presentations Rio Mar 6

10:30am - 11:30am Panel: Brachial Plexus Surgery 2007 Rio Mar 6

12:30pm - 4:00pm ASRM Master Series in Microsurgery Rio Mar 6

12:30pm Shot Gun 11th Annual Day at the Links River Course

6:00pm - 7:30pm ASRM International Reception Ocean Terrace

6:30pm - 8:00pm ASPN Welcome Reception Club Coqui

60 9:48am - 9:50am AAHS/ASRM/ASPN Discussion Saturday, January 13, 2007

6:30am – 7:30am Continental Breakfast ASPN Moderator: Robert J. Spinner, MD 7:00am – 8:00am Panel: Upper Extremity Injuries in Modern Warfare 9:50am - 9:58am This symposium given by members of the active *The Genetic Modification of the Human Sural Nerve Using Lentiviral Vectors military will detail the advances in the treatment of Institution where the work was prepared: Netherlands Institute for Neuroscience, upper extremity war injury from the battlefield Amsterdam, Netherlands through reconstruction and prosthetics. Martijn R. Tannemaat, MD; Gerard J Boer; Joost Verhaagen; Martijn J.A. Malessy CDR Erik Hofmeister, MD CDR Michael A. Thompson, MD CDR Michael T. Mazurek, MD 9:58am - 10:00am Discussion 8:00am – 8:10am AAHS/ASRM/ASPN Presidents Welcome

10:00am - 10:08am A comparison study between single, double or triple nerve transfer for shoul- der abduction in avulsed brachial plexus injury: Revisiting after 1000 case Ronald Palmer, MD, AAHS President experiences Institution where the work was prepared: Chang Gung University Hospital, Taoyuan, Taiwan Alexander Cardenas-Mejia, MD; Kuang-Te Chen, MD; David CC Chuang; Yu-Te Lin, MD; Paul Tulley, MD L. Scott Levin, MD, FACS, ASRM President

10:08am - 10:10am Discussion Rajiv Midha, MD, ASPN President ASPS Presidential Remarks ASRM 8:10am – 9:10am AAHS/ASRM/ASPN Presidents Invited Lecture: Moderator: Michael Zenn, MD Richard H. Gelberman, MD

10:10am – 10:15am Cross Facial Nerve Grafting for Facial Paralysis with Incomplete Recovery Institution where the work was prepared: National Taiwan University Hospital, Identifying Targets for Clinical and Research Taipei, Taiwan Excellence in 2007 Yueh-Bih Chen Tang, MD, Ph, D; Hui-Hsiu Chang, resident; Hung-Chi Chen, MD, The purpose of this presentation is to present a FACS strategy for overcoming the fiscal and academic resource challenges that threaten research and educational productivity in 2007. Richard H. Gelberman, MD is the Fred C. Reynolds 10:15am – 10:18am Professor and Chairman of the Department of Discussion Orthopaedic Surgery at the Washington University School of Medicine and Chairman of Orthopaedic Surgery at Barnes-Jewish Hospital in St. Louis, 10:18am – 10:26am Missouri. Research on Traumatic Paraplegia: Microsurgical Connection of the Above the 9:10am – 9:30am Break with Exhibitors Lesion Cord with Peripheral Nerves (C.N.S.-P.N.S. Connection) Institution where the work was prepared: Fondazione ricerca lesioni mdollo 9:30am - 10:30am OUTSTANDING NERVE PAPER PRESENTATIONS spinale, Brescia, Italy *Designates resident/fellow paper presentations Giorgio Brunelli, Professor AAHS 10:26am – 10:30am Moderator: A. Lee Osterman, MD Discussion Jorge L. Orbay, MD

9:30am - 9:38am 10:30am – 11:30am Panel: Brachial Plexus Surgery 2007 This panel will discuss the current status of phrenic nerve Comparison of Return to Work: Endoscopic Cubital Tunnel Release versus transfer and of the CNS/PNS interface as well as other new Anterior Subcutaneous Transposition of the Ulnar Nerve nerve transfers. In addition, the panel will talk about the Institution where the work was prepared: Orthopaedic Specialists, Davenport, IA, management of a patient with an upper pattern injury USA present in six months after injury and the management of Tyson Cobb, MD; Patrick T Sterbank, PA-C a patient with a complete brachial plexus lesion presenting 3 months after injury. 9:38am - 9:40am Allan Belzberg, MD, Moderator Discussion Robert J. Spinner, MD, Moderator Prof. Rolfe Birch 9:40am - 9:48am Susan Mackinnon, MD A Detailed Cost and Efficiency Analysis of Performing Carpal Tunnel Surgery Jianguang Xu, MD, PhD, MBA in the Main Operating Room Versus the ambulatory Setting Institution where the work was prepared: Dalhousie University / Saint John Regional Hospital, Saint John, NB, Canada 12:30pm Shot Gun 11th Annual Day at the Links Martin R. LeBlanc, BSc, MD; Janice Lalonde, RN; Donald H. Lalonde, BSc, MSc, MD See page 16 for details

61 12:30pm – 4:00pm ASRM Master Series in Microsurgery The American Society for Reconstructive Microsurgery is pleased to present Part III of the “Masters Series in Microsurgery”. This course was instituted in 2005 to provide an in-depth description of state of the art techniques pertinent to the key flaps which incorporate the breadth of reconstructive surgery. An interactive video prepared by a master surgeon will highlight technical pearls and pitfalls and address novel solutions to critical reconstructive challenges. Each video will be followed by audience discussion and a commentary led by experts in the field. Additional registration is required. Attendance is complimentary to Resident and Fellows. A DVD of the session will be sent to all registrants of the course. Lunch will be provided.

12:30pm – 12:40pm Introductory Remarks Elisabeth K. Beahm, MD, FACS, Chair

12:40pm – 1:05pm Facial Recontouring Joseph Upton, MD, FACS

1:05pm – 1:15pm Discussion and Comments Robert Walton, MD, FACS

1:15pm – 1:40pm Thoracodorsal Artery Perforator (TDAP) Flap Moustapha Hamdi, MD

1:40pm – 1:50pm Discussion and Comments Maurice Nahabedian, MD, FACS

1:50pm – 2:15pm Superior Gluteal Artery Perforator (SGAP) Flap Bernard Chang, MD, FACS

2:15pm – 2:25pm Discussion and Comments Robert J. Allen, MD

2:25pm – 2:40pm Break

2:40pm – 3:05pm Vascularized Epiphyseal Transfer Marco Innocenti, MD

3:05pm – 3:15pm Discussion and Comments L. Scott Levin, MD, FACS

3:15pm – 3:40pm Esophageal Reconstruction Hung-Chi Chen, MD

3:40pm – 3:50pm Discussion and Comments Ron Yu, MD

6:00pm – 7:30pm ASRM International Reception Join us as we kick off the ASRM Annual Meeting with our International Reception, highlighting the countries represented in the organization. Hear our colleagues reflect on what ASRM has meant to them and their organizations. Tropical hors d’oeuvres and cocktails will be served on the Ocean Terrace.

The ASRM would like to thank ASSI for their generous sponsorship of this reception.

6:30pm - 8:00pm ASPN Welcome Reception Tropical breezes and ocean views will be the setting for this lively gathering at Club Coqui. Join us as we network and enjoy the dramatic beauty of the Island's outdoor scenery.

62 ASPN DAY-AT-A-GLANCE Saturday, January 13, 2007

6:00am - 5:00pm Speaker Ready Room San Cristobal

1:00pm - 2:00pm Invited Speaker: Prof. Xavier Navarro Acebes, MD, PhD Caribbean 2 & 3

2:00pm - 3:30pm Scientific Paper Presentations A Caribbean 2 & 3

3:30pm - 4:00pm Break with Exhibitors Rio Mar 5

4:00pm - 4:30pm Invited Speaker: Jianguang Xu, MD, PhD, MBA Caribbean 2 & 3

4:30pm - 5:00pm Invited Speaker: Prof. Rolfe Birch Caribbean 2 & 3

6:30pm - 8:00pm ASPN Welcome Reception Club Coqui & Ocean terrace

63 2:30pm - 2:32pm ASPN Discussion Saturday, January 13, 2007 2:32pm - 2:34pm 1:00pm – 2:00pm Invited Speaker: Prof. Xavier Navarro A 5 Year Fallow up of End to Side Vascularized Ulnar Nerve Graft for Brachial Acebes, MD, PhD Plexus Roots Avulsion Institution where the work was prepared: Iran Medical Sciences University, Tehran, Sponsored by: Iran Kamal S. Forootan, MD, FICS; Lida Jafari Saraf; Ahmad Maghari

Prof. Xavier Navarro Acebes, MD, PhD, Dept. Cell 2:34pm - 2:35pm Biology, Physiology and , Institute of Discussion Neurosciences, Universitat Autonoma de Barcelona, Bellaterra, Spain Tube Repair: Advances towards an Artificial 2:35pm - 2:39pm Nerve Graft *Metastatic Breast Cancer Recurrence to the Brachial Plexus - MRI Imaging Tube repair has emerged as an effective alternative to Characteristics direct suture or short grafts for repairing severed Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA peripheral nerves. However, simple tubes have a limit Helena Gerhardt Summers, MD; Kimberly Amrami; Robert Spinner, MD to regeneration depending upon the length of the gap. The characteristics of the guide wall, in terms of permeability, durability and adhesiveness, also influ- 2:39pm - 2:41pm ence regeneration. Taking into account the impor- Discussion tance of the cellular component in regeneration, the development of an artificial graft, composed of a biocompatible nerve guide filled with a neurotropic 2:41pm - 2:43pm matrix and seeded with Schwann cells, is a reason- Outcome Measures in Brachial Plexus Reconstruction able option to enhance nerve regeneration and to Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA become an alternative to long autologous nerve Keith A. Bengtson, MD; Brian Kotajarvi, PT; Allen Bishop, MD; Robert Spinner, MD; grafting. Over the past years several of the techniques Alexander Shin, MD required to develop a transplantation program using Schwann cells prepared in culture have been achieved. However, the origin and the density of transplanted 2:43pm - 2:44pm cells determine the outcome. Coadjuvant treatment Discussion with FK506 allows for enhanced regeneration and also for preventing rejection of heterologous Schwann cell transplants. Moderators: Martijn J. A. Malessy, PhD Gedge Rosson, MD 2:00pm - 3:30pm SCIENTIFIC PAPER PRESENTATIONS SESSION A 2:44pm - 2:48pm *Designates resident/fellow paper presentations A Long Segmental Nerve Trunk Crush Injury Induces Increased Sprouting but does not Impair Peripheral Nerve Regeneration Moderators: Howard M. Clarke, MD, PhD Institution where the work was prepared: University of Calgary, Calgary, Canada Allan J. Belzberg, MD Qing Gui Xu; Rajiv Midha, MD; Douglas Zochodne

2:00pm - 2:06pm 2:48pm - 2:50pm A Method for Preoperative Evaluation of Brachial Plexus Birth Injuries Discussion Institution where the work was prepared: Miami Children’s Hospital, Miami, FL, USA 2:50pm - 2:54pm Ilker Yaylali, MD, PhD; Israel Alfonso, MD; John. A. I. Grossman, MD Alteration in Signaling Programs Demonstrated by Migrating Schwann Cells Institution where the work was prepared: Washington University in St. Louis, St. 2:06pm - 2:08pm Louis, MO, USA Discussion Ayato Hayashi, MD; Terence M. Myckatyn, MD; Alice Y. Tong, MS; Daniel A. Hunter, RA; Daniel Z. Liu, BA; Jason W. Koob, BA; Arash Moradzadeh, MD; Jamie 2:08pm - 2:14pm D. Gaertner; Thomas H. Tung, MD; Susan E. Mackinnon, MD *Intra-operative Neurophysiologic Recordings in Obstetric Brachial Plexus Lesions 2:54pm - 2:56pm Institution where the work was prepared: Leiden University Medical Center, Leiden, Discussion Netherlands Willem Pondaag, MD; J. Gert van Dijk; Martijn J.A. Malessy 2:56pm - 3:00pm 2:14pm - 2:16pm Atraumatic Electrophysiologic Evaluation of Nerve Regeneration Following Discussion Nerve Injuries of the Forelimb in Rats Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA 2:16pm - 2:22pm Huan Wang, MD, PhD; Eric J. Sorenson, MD; Anthony J. Windebank, MD; Robert Magnetic Resonance Imaging Diagnosis of Nerve Root Avulsion in J. Spinner, MD Birth-Related Brachial Plexus Injury Institution where the work was prepared: Children’s Healthcare of Atlanta, Atlanta, 3:00pm - 3:02pm GA, USA Discussion Ann Schwentker, MD; William Boydston, MD, PhD; Denis Atkinson, MD 3:02pm - 3:06pm 2:22pm - 2:24pm Development of Assessment Tasks for Evaluating Deficits and Recovery of Discussion Forelimb Function following Nerve Lesions in Rats 2:24pm - 2:30pm Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Severe Obstetric Brachial Plexus Injuries can be Identified Easily and Reliably Huan Wang, MD, PhD; Eric J. Sorenson, MD; John P. Bois, BA; Godard C.W. De at One Month of Age Ruiter, MD; Anthony J. Windebank, MD; Robert J. Spinner, MD Institution where the work was prepared: Leiden University Medical Center, Leiden, Netherlands 3:06pm - 3:08pm Martijn J.A. Malessy; W Pondaag; S.M Hofstede-Buitenhuis; S. le Cessie; J.G. van Dijk Discussion

64 3:08pm - 3:12pm challenges in C7 transfer, especially the difficulty in *Embryonic Stem Cell Derived Motor Neurons Form Neuromuscular Junctions achieving independent movement, are discussed. In Vitro and Enhance Motor Functional Recovery In Vivo Preliminary results of studies on brain plasticity follow- Institution where the work was prepared: Massachusetts General Hospital, Harvard ing contralateral C7 transfer will be reported. Other Medical School, Boston, MA, USA indications of C7 transfer, e.g. repair of Bell’s palsy, Tateki Kubo, MD, PhD; Mark Randolph, MAS; Jonathan M. Winograd, MD accessory nerve injury, and paraplegia, will also be discussed.

3:12pm - 3:14pm 4:30pm – 5:00pm Invited Speaker: Prof. Rolfe Birch Discussion Sponsored by:

3:14pm - 3:18pm *Accuracy of Motor Axon Regeneration After Different Types of Nerve Injury Prof. Rolfe Birch, Peripheral Nerve Injury Unit, Royal and Repair in the Rat Sciatic Nerve Model National Orthopaedic Hospital, Stanmore, Middlesex, Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA United Kingdom Godard C.W. De Ruiter, MD; M.J.A. Malessy; Robert J. Spinner, MD; A.O. Alaid; J.K. Engelstad; E.J. Sorenson, MD; K.R. Kaufman, PhD; P.J. Dyck, MD; A.J. Windebank, Iatropathic Injuries of Peripheral Nerves MD Incidence in the United Kingdom. A growing problem: defects in teaching; defects in training. Reasons for delay in recognition and in treatment: error in 3:18pm - 3:20pm diagnosis; failure to understand functional significance Discussion of the peripheral nervous system; failure to recognize the place of operation for diagnosis, for repair, for palliation. 3:20pm - 3:24pm The spinal accessory nerve: delay in diagnosis; *Reconstruction of a 40 mm Nerve Gap in Rats Using Biodegradable Nerve functional consequences; the significance of neuropath- Conduits Filled with Schwann Cells ic pain. The problem of the nerves of cutaneous Institution where the work was prepared: University of Tuebingen, Department of sensation: the particular vulnerability of the medial Handsurgery, Tuebingen/Germany, Germany cutaneous nerve of forearm, the superficial radial nerve Nektarios Sinis, MD; Max Haerle, MD; Stefan Becker, MD; Burkhard Schlosshauer, and the sural and the saphenous nerve. Injury to major PhD; Michael Doser, PhD; Harald Roesner, PhD; Klaus Dietz, MD; Hans-Werner nerves at the hip: predisposing factors; onset; expression Mueller, PhD; Hans-Eberhard Schaller, MD of neuropathic pain; depth of lesion; the indications for, and results of second operation. Hazards of interscalene 3:24pm - 3:26pm and other brachial plexus local blocks. The formation of Discussion the anterior spinal artery; the contribution of radicular vessels; their vulnerability to tamponade. The innervation of the shoulder joint. Recommendation 3:26pm - 3:28pm towards reduction of incidence of iatropathic lesion and Biodegradability of Synthetic Nerve Grafts Is Beneficial to Peripheral Nerve towards improvement in treatment. Regeneration Institution where the work was prepared: Leiden University Medical Centre, Department of Neurosurgery, Leiden, Netherlands 6:30pm – 8:00pm ASPN Welcome Reception Carmen L.A.M. Vleggeert-Lankamp, Drs; J.F.C. Wolfs; Ana P. Pego, Drs; R.J. van See page 16 for details den Berg; H.K.P. Feirabend; Martijn J.A. Malessy; E.A.J.F. Lakke

3:28pm - 3:29pm Discussion

3:30pm – 4:00pm Break with Exhibitors

4:00pm - 4:30pm Invited Speaker: Jianguang Xu, MD, PhD

Sponsored by:

Jianguang Xu, MD, PhD, MBA, President Huashan Hospital, Shanghai, Peoples Republic of China C7 Nerve Transfer: Past, Present and Future The talk features the evolution of contralateral C7 transfer, covering both experimental studies and clinical experience. Various studies have been conducted to answer questions concerning contralateral C7 transfer. What is the functional muscle innervation of each brachial plexus nerve root? What is the never fiber composition and distribution in C7 nerve root? Why is C7 nerve root dispensable and compensable, even in ipsilateral C7 transfer? What are the major considerations in selective/hemi-contralateral C7 root transfer and ipsilateral C7 transfer? Should contralateral C7 transfer be performed in a staged fashion? Can contralateral C7 nerve root be used to neurotize multiple recipient nerves? What is the optimal way and combination of doing so? New techniques such as prespinal routing in contralateral C7 transfer will be mentioned. Major challenges in C7 transfer,

65 ASPN DAY-AT-A-GLANCE Sunday, January 14, 2007

6:00am - 5:00pm Speaker Ready Room San Cristobal

6:00am - 7:00am Continental Breakfast with Exhibitors Rio Mar 5 & Ocean Terrace

6:30am - 1:30pm Meeting Services Rio Mar Atrium

7:00am - 8:15am ASPN Instructional Courses 201 Brachial Plexus Birth Palsy Rio Mar 4 202 Cortical Reorganization Rio Mar 7 203 Reinnervating Muscle Rio Mar 8 204 Peripheral Nerve Tumors Rio Mar 9 205 Intraoperative Monitoring Rio Mar 10

8:30am - 9:30am ASRM/ASPN Panel: Functioning Muscle Transfer Rio Mar 6

9:30am - 9:50am Break with Exhibitors Rio Mar 5

9:50am - 10:00am Welcome Remarks Caribbean 2 & 3

10:00am - 11:30am Scientific Paper Presentations B Caribbean 2 & 3

11:30am - 1:00pm Lunch Break (lunch not provided)

1:00pm - 2:00pm Invited Speaker: Tessa Gordon, PhD Caribbean 2 & 3

2:00pm - 4:00pm Scientific Paper Presentations C Caribbean 2 & 3

4:00pm - 4:15pm Closing Remarks & Presentation of Awards Caribbean 2 & 3

4:15pm - 4:45pm ASPN Business Meeting Caribbean 2 & 3

4:45pm - 5:15pm ASPN Council Meeting Caribbean 2 & 3

66 8:30am – 9:30am ASRM/ASPN Panel: Functioning ASPN Muscle Transfer Allen T. Bishop, MD, Moderator Sunday, January 14, 2007 David Chwei-Chin Chuang, MD Alexander Shin, MD 6:00am – 7:00am Continental Breakfast with Exhibitors Milan Stevanovic, MD

9:30am – 9:50am Break with Exhibitors 7:00am – 8:15am ASPN Instructional Courses

9:50am – 10:00am Welcome Remarks 201 Brachial Plexus Birth Palsy Rajiv Midha, MD, ASPN President Birth Related Brachial Plexus Injury (BRBPI) remains a controversial topic in terms of etiology, preven- tion, and management. For example, early versus delayed nerve surgery is hotly debated. We will explore various aspects of this injury using case based education. Robert Spinner, MD, ASPN Program Chair Allan Belzberg, MD Howard M. Clarke, MD, PhD Scott Kozin, MD

202 Cortical Reorganization Cortical plasticity follows peripheral nerve injury, 10:00am - 11:30am SCIENTIFIC PAPER regeneration and rehabilitation. PRESENTATIONS SESSION B Dimitri Anastakis, MD *Designates resident/fellow paper presentations Martijn Malessy, MD Moderators: Ivica Ducic, MD, PhD Marcel Meek, MD, PhD

203 Reinnervating Muscle 10:00am - 10:02am Motoneurons can reinnervate as many as 5 times as Pressure Changes in the Medial Plantar, Lateral Plantar, and Tarsal Tunnels many muscle fibers after injury and nerve repair as Related to Ankle Position: A Cadaver Study they normally do. This enlargement of the reinner- Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA vated motor unit size compensates for reduced Gedge D. Rosson, MD; Allison R. Barker; A. Lee Dellon numbers of motor nerves that succeed in regener- ating to reinnervate the denervated muscles. We will consider this issue of enlarged reinnervated 10:02am - 10:03am motor units in the context of whether regeneration Discussion of a smaller component of the normal number of nerves to a muscle is sufficient to restore 10:03am - 10:05am muscle function, even should the nerves regenerate TEM Chracteristic of Vibration Injury in Peripheral Nerves back to their original target muscles. We will also Institution where the work was prepared: Medical College of Wisconsin, consider the question of whether type grouping of Milwaukee, WI, USA muscle fibers after muscle denervation and Ji-Geng Yan, MD; Hani S. Matloub; Lin-Ling Zhang; James R. Sanger; Danny A. reinnervation and whether or not this type group- Riley, PhD ing is a sufficient basis for diagnosis of muscle denervation and reinnervation. 10:05am - 10:06am Paul Cederna, MD Discussion Tessa Gordon, PhD

10:06am - 10:08am Peripheral Nerve Injury after Hallux Abducto Valgus Surgery 204 Peripheral Nerve Tumors Institution where the work was prepared: Ankle and Foot Institute of Arizona, This instructional course will cover the evaluation Tucson, AZ, USA and management of benign and malignant Jerome K. Steck, DPM peripheral nerve tumors. Ab Guha, MD 10:08am - 10:09am Rajiv Midha, MD Discussion Robert Spinner, MD 10:09am - 10:13am *The Diagnostic Value of Ultrasound in Cubital Tunnel Syndrome Institution where the work was prepared: Wake Forest University School of 205 Intraoperative Monitoring Medicine, Winston-Salem, NC, USA Course attendees will learn how intraoperative G.D. Chloros, MD; Ethan R. Wiesler; Michael S. Cartwright; Hae W. Shin; Francis nerve action potentials, somatosensory evoked O. Walker potentials and motor nerve studies facilitate intraoperative decision making during surgery for 10:13am - 10:15am peripheral nerve lesions. The role of pre-opera- Discussion tive electromyography and nerve conduction studies as they relate to the intraoperative studies 10:15am - 10:19am will also be described. Ballistic Injuries of Peripheral Nerves: Imaging Aspects David Houlden, MD Institution where the work was prepared: Tel Aviv Sourasky Medical Center, Tel Robert Tiel, MD Aviv, Israel Allen Van Beek, MD Moshe Graif, MD; Shimon Rochkind, MD

67 10:19am - 10:21am 10:59am - 11:01am Discussion Discussion

10:21am - 10:23am 11:01am - 11:05am Treatment of Painful Neuroma by End-to-End Neurorraphy and a Nerve *A New and Novel Model of Peripheral Nervous System Response to Conduit Experimental Immunological Demyelination Institution where the work was prepared: Georgetown University Hospital, Institution where the work was prepared: University of California, Irvine, Orange, Washington, DC, USA CA, USA Ivica Ducic, MD, PhD; Ali Al-Attar, MD Aaron M. Kosins, BS; Michael P. McConnell, MD; Charles Mendoza; Brandon Shepard; Sanjay Dhar, PhD; Gregory RD Evans, MD, FACS; Hans S. Keirstead, PhD 10:23am - 10:24am Discussion 11:05am - 11:07am Discussion 10:24am - 10:28am Ballistic Injuries of Peripheral Nerves: Clinical Aspects 11:07am - 11:13am Institution where the work was prepared: Tel Aviv Sourasky Medical Center, Tel *Demystifying Histomorphometry: A Serial Approach to Nerve Morphometry Aviv, Israel Institution where the work was prepared: Washington University School of Shimon Rochkind, MD; Tzvi Shlitner, MD; Malvina Alon, MD; Nachum Medicine, St. Louis, MO, USA Chudnovsky, MD; Moshe Graif, MD Arash Moradzadeh, MD; Elizabeth L. Whitlock, BA; Susan E. Mackinnon, MD; Daniel A. Hunter, RA 10:28am - 10:30am Discussion 11:13am - 11:15am Discussion Moderators: Jonathan M. Winograd, MD Tessa Gordon, PhD 11:15am - 11:19am *Induction of Regional Collateral Sprouting Following Muscle Denervation 10:30am - 10:35am Institution where the work was prepared: Washington University School of *The Cystic Transverse Limb of the Articular Branch: A Pathognomonic Sign Medicine, St. Louis, MO, USA for Peroneal Intraneural Ganglion Cysts at the Superior Tibiofibular Joint Arash Moradzadeh, MD; JW Koob, BA; Alice Tong; Ayato Hayashi, MD; Terence Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA M. Myckatyn, MD; Thomas H. Tung, MD; Susan E. Mackinnon, MD Nicholas M. Desy, BSc; Kimberly K.amrami, MD; Robert J. Spinner, MD 11:19am - 11:21am 10:35am - 10:37am Discussion Discussion 11:30am – 1:00pm Lunch Break (Lunch not provided) 10:37am - 10:41am *Functional Effects of Locally Applied Thyroid Hormones in Sciatic Nerve 1:00pm – 2:00pm Invited Speaker: Tessa Gordon, PhD Regeneration in Rats Institution where the work was prepared: National University of Athens, Athens, Sponsored by: Greece Ioannis Papakostas, Dr; Iordanis Mourouzis; Kostas Mourouzis; Constantinos Pantos; Nikolaos Gerostathopoulos; Dimitrios Ntallas, Dr; George Macheras, Dr; Tessa Gordon, PhD. Center for Neuroscience, Division of Efstathios Boviatsis, Dr and Rehabilitation, Faculty of Medicine, University of Alberta, Edmonton, Alberta 10:41am - 10:43am Emerging Strategies to Improve Outcome Discussion of Nerve Injury Despite the capacity for injured peripheral nerves to regenerate their axons, functional outcome may be poor, 10:43am - 10:47am especially for injuries that require axon regeneration over Peripheral Nerve Injury in the Axolotl: a Model of Embryonic Regeneration considerable distances. We established that the long durations that neurons remain chronically axotomized prior Institution where the work was prepared: New York University School of Medicine, to target reinnervation and the chronic denervation New York, NY, USA of the Schwann cells in the distal nerve stumps, severely Stephen M. Russell, MD; Kartik Krishnan; Mark Schweitzer; Zehava Rosenberg; curtail the success of axon regeneration, and in turn, func- tional recovery. I will review our data demonstrating the Moses Chao effectiveness of exogenous neurotrophic factors in sustain- ing the regenerative capacity of chronically axotomized motoneurons and a strategy of using cytokines to 10:47am - 10:49am reactivate Schwann cells, to promote their proliferation, and Discussion thereby to promote regeneration of axons through chronically denervated distal nerve stumps. A key and to date largely unrecognized site of considerable delay is the 10:49am - 10:53am surgical suture site. I will describe experiments in which we demonstrate that a very long period of 4 weeks is required Sensory Protection Modulates Neurotrophic Factor Expression in Distal Nerve for all neurons to regenerate their axons across the surgical Stump Following Denervation junction between proximal and distal nerve stumps in rats, Institution where the work was prepared: McMaster University, Hamilton, ON, the reported latent period of days corresponding only to a small proportion of the axons that cross the lesion site Canada within the time period. We found that low frequency Margaret Fahnestock, PhD; Bernadeta Michalski; James Bain, MD, MSc stimulation of the proximal nerve stump for just 1hour after surgery accelerates the axon outgrowth across the lesion site in association with up-regulation of neurotrophic factors in 10:53am - 10:55am the motor and sensory neurons. I will communicate our Discussion recent translation of these exciting findings to human patients who suffered moderate to severe carpal tunnel syndrome prior to surgery. We found that the same 1 hour period of electrical stimulation proximal to the site of carpal 10:55am - 10:59am tunnel release surgery promoted axon regeneration such The Source and Pattern of Motor Collateral Sprouting and Nerve Regeneration that the number of reinnervated motor units in the thenar in End-to-Side Nerve Repair of Nerve to Medial Gastrocnemius in the Rat muscles of the patient group of stimulation increased to normal levels within 6-8 months as compared to a trend for Institution where the work was prepared: Bernard O’Brien Institute of unstimulated median nerves to regenerate but Microsurgery, Melbourne, Australia for the motor unit numbers not to approach normal levels Alan Hussey, FRCS(Plast); Richard Brower; Aurora Messina; Wayne Morrison within 1 year of surgery. This significant increase found in

68 the numbers of reinnervated motor units with electrical 2:32pm - 2:38pm stimulation was accompanied by increased manual *Use of Skin-Derived Stem Cells to Promote Peripheral Nerve Regeneration and dexterity (Purdue Pegboard test), reduced symptom Recovery from Chronic Denervation severity (Levine symptom severity questionnaire), and Institution where the work was prepared: University of Calgary, Hotchkiss Brain improved skin sensation (Semmes-Weinstein monofila- Institute, Calgary, AB, Canada ments). These data indicate that electrical stimulation at the time of surgical repair is a feasible strategy to promote Sarah K. Walsh, BSc; J. Biernaskie; F. Miller; Raj Midha, MD, MSc axonal regeneration in humans and that it has the potential to improve functional outcomes after surgical 2:38pm - 2:40pm repair of injured peripheral nerves. This strategy opens Discussion opportunities to enhance axon regeneration after peripheral nerve injury by combining with brief electrical stimulation to promote axon out-growth across the 2:40pm - 2:44pm suture site with strategies to sustain both the regenerative Collagen Nerve Protectors in Rat Sciatic Nerve Repair: A Functional and capacity of the axotomized neurons and Schwann cell Mechanical Analysis support of the regenerating axons over distance and time. Institution where the work was prepared: Columbia University Medical Center, (I wish to thank the CIHR of Canada for their financial Department of Ortho. Surgery, New York, NY, USA support of this work). Austin G. Hayes, BS; Charles M. Jobin, MD; Yelena Akelina, DVM; Melvin P. Rosenwasser, MD 2:00pm - 4:00pm SCIENTIFIC PAPER PRESENTATIONS SESSION C 2:44pm - 2:46pm *Designates resident/fellow paper presentations Discussion

Moderators: Paul S. Cederna, MD 2:46pm - 2:50pm Maria Siemionow, MD, PhD In Vivo Enhancement of Spinal Axon Outgrowth by Sialidase in a Rat Model of Brachial Plexus Avulsion Institution where the work was prepared: Johns Hopkins School of Medicine, 2:00pm - 2:04pm Baltimore, MI, USA A Novel Method of Head Fixation for the Study of Rodent Facial Function Lynda js Yang, MD, PhD; Ronald Schnaar, PhD Institution where the work was prepared: Massachusetts Eye and Ear Infirmary, Boston, MA, USA 2:50pm - 2:52pm Tessa A. Hadlock, MD; Susan Mackinnon; James T. Heaton, PhD Discussion

2:04pm - 2:06pm 2:52pm - 2:56pm Discussion *Effects of Motor Versus Sensory Nerve Architecture on Regeneration Through Cold Preserved Nerve Grafts Institution where the work was prepared: Washington University School of 2:06pm - 2:10pm Medicine, St. Louis, MO, USA Small Fibers Dysfunction during Entrapment Neuropathy and after Surgical Arash Moradzadeh, MD; Christopher M. Nichols, MD; Jason W. Koob, BA; Daniel Decompression in a Rat Model A. Hunter, RA; Susan E. Mackinnon, MD Institution where the work was prepared: Ching-Hua Hsieh, Kaohsiung, Taiwan Ching-Hua Hsieh, MD; Tsu-Hsiang Lu, BA; Seng -Feng Jeng, MD; Shun-Sheng 2:56pm - 2:58pm Chen, MD, PhD Discussion

2:10pm - 2:12pm 2:58pm - 3:02pm Discussion Live image analysis of Schwann cell-axonal relationship in peripheral nerve allografts 2:12pm - 2:16pm Institution where the work was prepared: Washington University in St. Louis Harvested Human Neurons Engineered as Live Nervous Tissue Constructs: School of Medicine, St. Louis, MO, USA Implications for Transplantation Ayato Hayashi; Terence M. Myckatyn, MD; Alice Y. Tong, MS; Daniel A. Hunter, Institution where the work was prepared: University of Pennsylvania, Philadelphia, RA; Daniel Z. Liu, BA; Jason W. Koob, BA; Arash Moradzadeh, MD; Jamie D. PA, USA Gaertner; Thomas H. Tung, MD; Susan E. Mackinnon, MD Eric L. Zager, MD; Jason H. Huang, MD; Jun Zhang, MD; Robert G. Groff, BA; Bryan J. Pfister, PhD; Eileen Maloney-Wilensky, CRNP; Akiva S. Cohen, PhD; M. 3:02pm - 3:04pm Sean Grady, MD; Douglas H. Smith, MD Discussion

2:16pm - 2:18pm Moderators: A. Lee Dellon, MD Discussion Thomas Tung, MD

2:18pm - 2:24pm 3:04pm - 3:10pm *In Vivo Bioluminescence Imaging of Schwann cells in a Nerve Conduit *Multiple Costimulatory Pathway Inhibition for Nerve Allograft Regeneration Institution where the work was prepared: Department of Plastic Surgery, Institution where the work was prepared: Washington University in St. Louis Groningen, Netherlands School of Medicine, St. Louis, MO, USA M.S. Ma; J.C.V.M. Copray; G.M. van Dam; H.W.G.M. Boddeke; M.F. Meek, MD, PhD Chau Y. Tai, MD; Jaime Gaertner; Dan A Hunter; Thomas H Tung

2:24pm - 2:26pm 3:10pm - 3:12pm Discussion Discussion

2:26pm - 2:30pm 3:12pm - 3:16pm *Nerve Fiber and Motor Neuron Count Variation with Time After Nerve Injury *A Dose Dependent Facilitation and Inhibition of Early Peripheral Nerve Institution where the work was prepared: Washington University, Saint Louis, MO, Regeneration by Nerve Growth Factor (NGF) Through a Novel T-tube Chamber: USA Effects on the Establishment of an In Vivo Concentration Gradient Ida K. Fox, MD; Daniel A. Hunter; Susan E. Mackinnon Institution where the work was prepared: University of Calgary and the Hotchkiss Brain Institute, Calgary, AB, Canada 2:30pm - 2:32pm Stephen W.P. Kemp, BSc(Hons), MSc; Sarah K. Walsh, BSc; Douglas Zochodne; Raj Discussion Midha, MD, MSc

69 3:16pm - 3:18pm Discussion

3:18pm - 3:22pm An Alternate Nociceptive Drive: The Role of Afferent-Efferent Propioceptive System in the Maintenance of Chronic Pain States Institution where the work was prepared: Hand and Microsurgery Center of El Paso, El Paso, TX, USA Jose Monsivais, MD; Kris Robinson, PhD, FNP

3:22pm - 3:24pm Discussion

3:24pm - 3:28pm Effect of Levetiracetam and Morphine in an Animal Model of Neuroma Pain Institution where the work was prepared: Johns Hopkins, Baltimore, MD, USA Lun Chen; Richard Meyer; Michael Dorsi; Allan J. Belzberg, MD

3:28pm - 3:30pm Discussion

3:30pm - 3:34pm The Effect of Cold Storage on Somatosensory Function of Allogenic Nerve Transplants Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Michal Molski; Yalcin Kulahci; Ilker Yazici; Maria Siemionow

3:34pm - 3:36pm Discussion

3:36pm - 3:40pm *The Behavioral and Immunological Effect of GM-1 Ganglioside on Nerve Root Regeneration Following C5 Nerve Root Avulsion In a Rat Model Institution where the work was prepared: Rush University Medical Center, Chicago, IL, USA Harold Gregory Bach, MD; Heather Harrison, BS; Bassem El Hassan, MD; James M. Kerns, PhD; Robert M. Leven, PhD; Mark Gonzalez, MD

3:40pm - 3:42pm Discussion

3:42pm - 3:46pm Cryopreservation of Epineural Sheath Conduits Gives Similar Functional Results as Cold Storage Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Michal Molski; Yalcin Kulahci; Ilker Yazici; Maria Siemionow

3:46pm - 3:48pm Discussion

3:48pm - 3:50pm Outcome of Neurolysis for Failed Tarsal Tunnel Syndrome Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA A. Lee Dellon, MD; Allison R. Barker, BA; Gedge D. Rosson

3:50pm - 3:51pm Discussion

3:51pm - 3:53pm Prospective Comparison of Electrodiagnostic and Neurosensory Testing in Patients with Neuropathic Symptoms of Lower Limbs Institution where the work was prepared: Chicago Peripheral Nerve Center, Chicago, IL, USA Roberto P. Segura, MD; Edgardo R. Rodriguez

3:53pm - 3:54pm Discussion

4:00pm – 4:15pm Closing Remarks and Presentation of Awards 4:15pm – 4:45pm ASPN Business Meeting (Attendance is limited to ASPN members only)

4:45pm – 5:15pm ASPN Council Meeting

70 ASRM DAY-AT-A-GLANCE Sunday, January 14, 2007

6:00am - 5:00pm Speaker Ready Room San Cristobal

6:00am - 7:00am Continental Breakfast with Exhibitors Rio Mar 5 & Ocean Terrace

6:30am - 1:30pm Meeting Services Rio Mar Atrium

7:00am - 2:00pm Patient Safety Computerized Presentations Egret DVT Prevention Fire Safety Infection Control Laser Safety OSHA Blood Borne Pathogen Safety

7:00am - 7:15am Welcome Rio Mar 6

7:15am - 8:30am Concurrent Scientific Paper Presentations A-1 Rio Mar 6

7:15am - 8:30am Concurrent Scientific Paper Presentations A-2 Caribbean 1

8:30am - 9:30am ASRM/ASPN Panel: Functioning Muscle Transfer Rio Mar 6

9:30am - 9:50am Break with Exhibitors Rio Mar Foyer

9:50am - 10:30am Concurrent Scientific Paper Presentations B-1 Rio Mar 6

9:50am - 10:30am Concurrent Scientific Paper Presentations B-2 Caribbean 1

10:30am - 11:30am Presidential Address Rio Mar 6

11:30am - 12:30pm Godina Lecturer: Ming Huei Cheng, MD, MHA Rio Mar 6

12:30pm - 1:30pm ASRM Mentor Luncheon (by invitation only) Rio Mar 1

12:30pm - 7:00pm Break - at your leisure

6:30pm - 9:30pm Meeting Services Rio Mar Atrium

7:00pm - 9:00pm ASRM “Pamper Package” Guest Program Caribbean 1

7:00pm - 8:00pm Limb Salvage Versus Amputation - What’s New? Rio Mar 6

8:00pm - 9:00pm Best Microsurgical Save of the Year Rio Mar 6

9:00pm - 10:00pm Best Microsurgical Case of the Year Rio Mar 6

71 7:40am – 7:43am ASRM Timing and Predictors of Arterial and Venous Thrombosis Following Sunday, January 14, 2007 Autologous Free TRAM Breast Reconstruction Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA 6:00am – 7:00am Continental Breakfast with Exhibitors Michel Saint-Cyr, MD; David W. Chang, MD 7:00am – 2:00pm Patient Safety Computerized Presentations Computerized patient safety modules will be available throughout the meeting for individual use 7:43am – 7:46am (1 CME hour each). In addition to the CME received The SIEA Flap Revisited: New and Improved Techniques for meeting attendance, these modules will allow Institution where the work was prepared: The Methodist Hospital, Houston, TX, attendees to increase the designated patient safety USA CME received. Aldona J. Spiegel, MD; Farah Naz Khan, MD 7:00am – 7:15am Welcome 7:46am – 7:49am *A Head to Head Comparison of the SIEA Flap and the Muscle Sparing Free TRAM: Is the Rate of Flap Loss Worth the Gain in Abdominal Wall Function? L. Scott Levin, MD, FACS, ASRM President Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA Jesse Creed Selber, MD, MPH; Stephen J. Vega, MD; Seema Sonnad; Joseph Serletti Michael Zenn, MD, ASRM Program Chair 7:49am – 7:55am 7:15am - 8:30am SCIENTIFIC PAPER Discussion PRESENTATIONS SESSION A-1 *Designates resident/fellow paper presentations 7:55am – 7:58am Blood Supply of Abdominal flaps for Breast Reconstruction Moderators: Elisabeth Beahm, MD Institution where the work was prepared: University Hospitals, Leuven, Belgium Maurice Nahabedian, MD Marc Vandevoort, MD; Pieter Vermeulen; Gerd Fabre; Jan Jeroen Vranckx

7:15am – 7:18am 7:58am – 8:01am *The Use of Three-Dimensional CT Angiography for Preoperative Mapping of *Outcome after Revision of Autologous Breast Reconstruction with Abdominal Wall Perforating Vessels for Autologous Perforator-Based Microvascular Free DIEP, SIEA and SGAP Flap Microsurgical Breast Reconstruction Institution where the work was prepared: UZ Leuven Gasthuisberg, Leuven, Institution where the work was prepared: Johns Hopkins University School of Belgium Medicine, Baltimore, MD, USA Pieter Vermeulen, MD; Marc Vandevoort; Gerd Fabre; Jan Jeroen Vranckx Christopher G. Williams, MD; Navin K. Singh, MD; Elliot K. Fishman, MD; Gedge D. Rosson, MD 8:01am – 8:04am Double-Pedicle Abdominal Perforator Free Flaps for Unilateral Breast 7:18am – 7:21am Reconstruction Preoperative Planning of the Abdominal Perforator Flaps with the Multi- Institution where the work was prepared: Gent University Hospital – Plastic and Detector CT Scan (MDCT): 3 Years of Experience Reconstruction Department, Gent, Belgium Institution where the work was prepared: Sant Paul University Hospital, Bracelona, Spain Jaume Masia, MD, PhD; J. A. Clavero, MD Moustapha Hamdi, MD; Dana K. Khuthaila, MD; Koenraad Van Landuyt, MD; Nathalie Roche, MD; Stan Monstrey, MD, PhD

7:21am – 7:25am Discussion 8:04am – 8:10am Discussion

7:25am – 7:28am 8:10am – 8:13am *A Comparison of Postoperative Sequelae in Free TRAM and DIEP Flaps for The Sensational Breast Reconstruction: Innervated versus Non-Innervated Breast Reconstruction Flaps Institution where the work was prepared: Memorial Sloan-Kettering Cancer Center, Institution where the work was prepared: The Methodist Hospital, Houston, TX, New York, NY, USA USA Constance M. Chen, MD, MPH; Eric Halvorson; Joseph J. Disa; Babak J. Mehrara; Aldona J. Spiegel, MD; Farah Naz Khan, MD; Michael Charles Edwards, MD/PhD; Andrea L. Pusic; Peter G. Cordeiro Joe P. Day, PhD

7:28am – 7:31am 8:13am – 8:16am *A Meta-Analysis of Complication Rates in Free DIEP versus Free TRAM Flaps The Semi-Lunar Transverse Inner Thigh Flap for Microvascular Breast for Breast Reconstruction Reconstruction: An Excellent Alternative to Abdominal Flaps Institution where the work was prepared: Div of Plastic Surgery, Hosp of the Institution where the work was prepared: California Pacific Medical Center, San University of Pennsylvania, Philadelphia, PA, USA Francisco, CA, USA Li-Xing Man, MD, MSc; Jesse C. Selber, MD, MPH; Joseph M. Serletti, MD, FACS Rudolf F. Buntic, MD; Darrell Brooks, MD; Karen M. Horton, MD, MSc

7:31am – 7:34am 8:16am – 8:19am *A Comparison of Donor Site Morbidity of the SIEA, DIEP, and ms-TRAM Flaps *Congenital Breast Deformity Reconstruction using Perforator Flaps for Breast Reconstruction Institution where the work was prepared: Louisiana State University Medical Institution where the work was prepared: MD Anderson Cancer Center, Houston, School, New Orleans, LA, USA TX, USA Abhinav K. Gautam, BS; Timothy S. Mountcastle; Joshua L. Levine; Robert J. Liza C. Wu, MD; Anureet Bajaj; David W. Chang, MD; Pierre Chevray, MD, PhD Allen; Ernest S. Chiu

7:34am – 7:40am 8:19am – 8:30am Discussion Discussion

72 7:15am – 8:30am SCIENTIFIC PAPER 7:54am – 8:00am PRESENTATIONS SESSION A-2 Discussion *Designates resident/fellow paper presentations 8:00am – 8:03am Prevention of First Web Retraction in Traumatic Cases with Emergency Buried Moderators: Gunter Germann, MD Free Flaps Gabriel Kind, MD Institution where the work was prepared: Clinica Aston, Valencia, Spain Pedro C. Cavadas, MD, PhD 7:15am – 7:18am Replantation in Developing Countries 8:03am – 8:06am Institution where the work was prepared: SOS Mano Santo Domimngo, Hand *Arterial Reconstruction for Ulnar Artery Thrombosis group, Santo Domimngo, Dominican Republic Institution where the work was prepared: Wake Forest University School of Hector Herrand, MD; Marcos Nuñez, MD; Otoniel Diaz, MD Medicine, Winston-Salem, NC, USA G.D. Chloros, MD; Robert M. Lucas; Martha Holden; L. Andrew Koman

7:18am – 7:21am 8:06am – 8:09am Reconstruction of Congenital Differences of the Hand Using Microsurgical Toe *A Multicenter Study on the Use of Free Flaps to Preserve Upper Extremity Transfers Amputation Levels Institution where the work was prepared: University of California, Los Angeles, Los Institution where the work was prepared: Duke University Medical Center, Durham, Angeles, CA, USA NC, USA Neil F. Jones, MD Alessio Baccarani, MD; Keith E. Follmar; Giorgio De Santis, Professor; Roberto Adani; Massimo Pinelli; Marco Innocenti, MD; Steffen P. Baumeister; Henning von 7:21am – 7:24am Gregory; Günter Germann; Detlev Erdmann; L. Scott Levin *Simultaneous Double Second Toe Transplantation for Reconstruction of Multiple Digit Loss in Traumatic Hand Injuries 8:09am – 8:15am Institution where the work was prepared: The Buncke clinic and Division of Discussion Microsurgery, CPMC, San Francisco, CA, USA Fernando A. Herrera Jr, MD; Alfonso Camberos, MD; Jacob J. Freiman; Charles K. 8:15am – 8:18am Lee; Rudy Buntic; Gregory M. Buncke Free Flap Reconstruction Extends the Indications for Forequarteramputation Institution where the work was prepared: Helsinki University Hospital, Helsinki, Finland 7:24am – 7:30am Erkki Tukiainen; Outi Kaarela, MD, PhD Discussion

8:18am – 8:21am 7:30am – 7:33am *Radical Reduction of Upper Extremity Lymphedema with Preservation of *Functional Assessment of the Reconstructed Fingertips after Free Toe Pulp Perforators (RRPP) Transfer Institution where the work was prepared: E-Da Hospital / I-Shou University, Institution where the work was prepared: Cheng-Hung Lin, Taipei, Taiwan Kaohsiung, Taiwan Cheng-Hung Lin, MD; Chih-Hung Lin; Yu-Te Lin; Paolo Sassu; Fu-Chan Wei Paolo Sassu

7:33am – 7:36am 8:21am – 8:24am Osteoplastic Thumb Ray Restoration with Secondary Toe Transfer for Restoration of Dynamic External Rotation by Muscle Transfers in OBPP Opposable Basic Hand Reconstruction Institution where the work was prepared: Mircosurgical Research Center, EVMS, Institution where the work was prepared: Chang Gung Memorial Hospital, Norfolk, VA, USA Taoyuan county, Taiwan Julia K. Terzis, MD, PhD; Epaminondas Kostopoulos, M.D. Chih-Hung Lin; Yu-Te Lin; Yu-Te Lin; Cheng-Hung Lin; Cheng-Hung Lin; Samir Mardini; Fu-Chan Wei 8:24am – 8:30am Discussion 7:36am – 7:39am *Metacarpal Bone Missing in Childhood: Reconstruction by Free Vascularized 8:30am – 9:30am ASRM/ASPN Panel: Functioning Muscle Transfer Iliac Bone Graft Including its Cartilage for Bone Growth Consideration Allen T. Bishop, MD, Moderator Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, Taiwan David Chwei-Chin Chuang, MD Chao-yi Lai Alexander Shin, MD Milan Stevanovic, MD 7:39am – 7:45am Discussion 9:30am – 9:50am Break with Exhibitors

7:45am – 7:48am 9:50am - 10:30am SCIENTIFIC PAPER Our Experience with Proximal Free Fibular Head Flap for Articular PRESENTATIONS SESSION B-1 Reconstructions *Designates resident/fellow paper presentations Institution where the work was prepared: The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel Moderators: Mustafa Akyurek, MD Arik Zaretski, MD; Aharonamir; David Leshem; Yoav Barnea; Jerry Weiss; Yehuda Joseph Disa, MD Kollender, MD; Jacob Bickels; Izzac Meller; Eyal Gur 9:50am – 9:53am 7:48am - 7:51am Functional Reconstruction of Complex Lip Defect with One Free Composite *Radial Nerve Palsy: Classification, Treatment and Result- 300 Cases Study Anterolateral Thigh Fascia-Cutaneous Flap Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, Institution where the work was prepared: Chang Gung Memorial Hospital, Taiwan Kaohsiung, Taiwan Chun-Hao Pan; David, Chwei-Chin Chuang Yur-Ren Kuo; Seng-Feng Jeng; Jir-Wen Yin, MD; Ching-Hua Hsien

7:51am – 7:54am 9:53am – 9:56am Restoration of Axillary Nerve Function by Neurotization from the Radial Nerve: Facial Reanimation with the Masseter-to-Facial Nerve Transfer: Initial Our Early Experience Experience Institution where the work was prepared: Duke Unversity Medical Center, Durham, Institution where the work was prepared: The Methodist Hospital - Institute for NC, USA Reconstructive Surgery, Houston, TX, USA Julian McClees Aldridge III, MD; James A. Nunley Michael Klebuc, MD

73 9:56am – 10:00am 9:53am – 9:56am Discussion *Fasciocutaneous versus Muscle Flaps Following Lower Extremity Trauma: A Pilot Study of Functional Outcomes 10:00am – 10:03am Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Resurfacing of Color-Mismatched Free Flaps on the Face With Split Thickness Baltimore, MD, USA Skin Grafts From the Scalp Rachel Bluebond-Langner, MD; Navin K. Singh, MD; Gedge D. Rosson, MD; Suhail Institution where the work was prepared: University Health Network, Toronto, ON, Mithani; Eduardo D. Rodriguez, DDS, MD Canada Declan A. Lannon, MB, BCh, BAO, FR; Christine B. Novak, PT, MS, PhD(c); Peter 9:56am – 10:00am C. Neligan, MB, FRCSC, FACS Discussion

10:03am – 10:06am 10:00am – 10:03am Marriage of Hard and Soft Tissues of the Face Revisited: When Distraction Shift of Concepts in the Management of Open Tibial Fractures Meets Microsurgery Institution where the work was prepared: Department of Hand, Plastic and Institution where the work was prepared: New YorkUniversity School of Medicine, Reconstructive Surgery, Ludwigshafen, Germany New York, NY, USA Christoph Heitmann; Christoph Czermak; Emilios Nalbantis; Günter Germann Jason Spector, MD; Pierre Saadeh; Stephen M Warren; Sunil P Singh; Pierre Boutros Saadeh; Joseph G McCarthy; John W Siebert 10:03am – 10:06am *Gustilo Grade IIIB Tibial Fractures Requiring Microvascular Free Flaps: 10:06am – 10:10am External Fixation Versus Intramedullary Rod Fixation Discussion Institution where the work was prepared: NYU Medical Center/Bellevue Hospital, New York, NY, USA 10:10am – 10:13am Christine Rohde, MD; Matthew R. Greives; Curtis L. Cetrulo Jr, MD; Oren Z. *Safety and Reliability of the Ulnar Artery Perforator Flap Lerman, MD; Alexes Hazen, MD; Jamie P. Levine, MD Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Baltimore, MD, USA 10:06am – 10:10am Suhail K. Mithani, MD; Rachel Bluebond-Langner, MD; Gedge D. Rosson, MD; Discussion Eduardo D. Rodriguez, DDS, MD

10:13am – 10:16am 10:10am – 10:13am Combining Split Inferior Turbinate (SIT) Mucosal Flaps with Free Flap for Pitfalls in Reconstruction of Heel Defects Due to Ground Landmine Explosions Repairing Nasal Cavity in Composite Palatal and Maxillary Defect Institution where the work was prepared: Gulhane Military Medical Academy. Reconstructions Depart. of Plastic Surgery, Ankara, Turkey Institution where the work was prepared: Chang Gung memorial hospital, Taipei, Serdar Ozturk, Assoc, Prof; Mustafa Sengezer; Fatih Zor; Murat Turegun Taiwan C.K. Tsao; Ming-Huei Cheng; Chwei-Chin Chuang; Fu-Chan Wei 10:13am – 10:16am 10:16am – 10:20am *Achilles Tendon Reconstruction with the Gracilis Musculotendinous Free Discussion Tissue Transfer: A Single-Institution Experience Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, USA 10:20am - 10:23am Bauback Safa, MD; Charles K. Lee; Gil S. Kryger, MD; Gregory M. Buncke *The Alliance of Craniofacial and Microsurgery in Composite Mid-Face Reconstruction: Introduction of the Girder System Using the Free Fibula Osteoseptocutaneous Flap 10:16am – 10:20am Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Discussion Baltimore, MD, USA Julie E. Park, MD; Rachel Bluebond-Langner, MD; Paul N. Manson, MD; Eduardo D. Rodriguez, DDS, MD 10:20am – 10:23am *Fibula Free Flap Reconstruction of the Ilium in Children after Resection of the Hemipelvis 10:23am – 10:26am Institution where the work was prepared: Children's Hospital of Philadelphia & Immediate Free Flap Reconstruction in the Management of Advanced University of Pennsylvania, Philadelphia, PA, USA Mandibular Osteoradionecrosis Darrin M. Hubert, MD; John P. Dormans, MD; David W. Low, MD; Benjamin Institution where the work was prepared: National Taiwan University Hospital, Chang, MD Taipei, Taiwan Nai-Chen Cheng, MD; Ming-Ting Chen; Hao-Chi Tai; Yueh-Bih Tang

10:23am – 10:26am 10:26am – 10:30am *A long-Term Study Of Donor Site With A Split Fibula Bone Graft After Discussion Vascularized Fibula Flap Transfer In Head And Neck Surgery Institution where the work was prepared: Chang Gung Memorial Hospital, 9:50am - 10:30am SCIENTIFIC PAPER Kaohsiung, Taiwan PRESENTATIONS SESSION B-2 Shun-Man Cheung, MD; Seng-Feng Jeng; Yur-Ren Kuo; Ching-Hua Hsien *Designates resident/fellow paper presentations

10:26am – 10:30am Moderators: Raymond Dunn, MD Discussion Detlev Erdmann, MD

9:50am – 9:53am 10:30am – 11:30am Presidential Address *Long term results in the use muscle flaps for salvage of the infected total knee arthroplasties Institution where the work was prepared: cleveland clinic, clinic, OH, USA amardip Bhuller, md; Wong Moon, MD; Risal Djohan, MD; Warren Hammert; Earl Browne, MD L. Scott Levin, MD, FACS

74 11:30pm – 12:30pm Godina Lecturer: Ming Huei Cheng, MD, MHA

“Marko Godina was distinguished by his tireless energy, his impeccable logic, his boundless optimism, and his constant good humor and courtesy” – G. Lister It is these qualities that are sought after in choosing the ASRM Godina Lecturer, honoring Dr. Marko Godina, an unrivaled leader and innovator in reconstructive microsurgery whose life was tragically cut short at the young age of 43. Established by the trustees of the Marko Godina Fund, this distinguished lectureship highlights a young, upcoming microsurgeon who has demonstrated leadership, innovation and ongoing commitment to our field in the best traditions of Dr. Godina. Ming Huei Cheng, MD is the 2006 Godina Traveling Fellow. An Empty Glass- Filling, Sharing and Refilling, a Never-Ending Quest for Universal Knowledge Knowledge, techniques and experience should be shared to achieve our common goals of conquering new frontiers in reconstructive microsurgery and improving treatments for our patients. It is my endeavor to teach what I have learned and share what I have received. Ming Huei Cheng, MD, MHA is Assistant Professor and Chairman of the Division of Microsurgery and Hand in the Department of Plastic and Reconstructive Surgery at Chang Gung Memorial Hospital in Tao-Yuan, Taiwan. After completing his residency in Plastic Surgery at Chang Gung Memorial Hospital in Taiwan, Dr. Cheng completed his research fellowship at The University of Texas M.D. Anderson Cancer Center and continued on in the US as a visiting scholar at Emory University, Louisiana State University Medical Center and the University of California – Los Angeles. He returned to Taiwan to complete his Executive Master of Health Administration at Chang Gung University.

12:30pm – 1:30pm ASRM Mentor Luncheon (invitation Only)

12:30pm – 7:00pm Break – at your leisure

7:00pm – 9:00pm ASRM “Pamper Package” Guest Program See page 16 for details

7:00pm – 8:00pm Limb Salvage Versus Amputation – What’s New? Recent advances in the treatment of devastating lower extremity injuries will be discussed. Factors influencing the decision regarding salvage attempt vs. amputation will be outlined. Jean-Paul Bosse, MD Samuel Lin, MD Emmanuel Melissinos, MD

8:00pm – 9:00pm Best Microsurgical Save of the Year Award The "Best Microsurgical Save of the Year" Award will be presented, based on submissions from the membership of microsurgical salvage cases performed during the last year. A panel of experts will critique submitted cases and the membership present will vote for the best case. Michael Zenn, Moderator The ASRM would like to thank Synovis for their generous sponsorship of this award.

9:00pm – 10:00pm Best Microsurgical Case of the Year Award The "Best Microsurgical Case of the Year" Award will be presented, based on submissions from the membership during the year. A portion of the case must have been performed during the past year. A panel of experts will critique submitted cases and the membership present will vote for the best case. Randy Sherman, MD, Moderator The ASRM would like to thank Synovis for their generous sponsorship of this award.

75 ASRM DAY-AT-A-GLANCE Monday, January 15, 2007

6:00am - 8:00am Continental Breakfast Rio Mar Foyer & Ocean Terrace

6:00am - 1:00pm Speaker Ready Room San Cristobal

6:30am - 1:00pm Meeting Services Rio Mar Atrium

7:00am - 2:00pm Patient Safety Computerized Presentations Egret DVT Prevention Fire Safety Infection Control Laser Safety OSHA Blood Borne Pathogen Safety

7:00am - 8:00am Instructional Courses 301 Refinements in Mandible Reconstruction Rio Mar 2 302 Foot & Ankle Reconstruction Rio Mar 3 303 Treatment of the Mutilated Hand Rio Mar 4 304 Esophageal Reconstruction Rio Mar 7 305 Microsurgical Salvage of Breast Reconstruction Rio Mar 8 306 Microsurgical Research & Funding Rio Mar 9 307 Facial Reanimation Rio Mar 10

8:00am - 8:30am Past President’s Breakfast (by invitation only) Board Room

8:00am - 9:00am Instructional Courses 308 Microsurgical Breast Reconstruction Rio Mar 2 309 Prefabrication of Flaps Rio Mar 3 310 CPT Coding and Reimbursement Rio Mar 4 311 Management of Chronic Pain Rio Mar 7 312 Management of the Ischemic Upper Extremity Rio Mar 8 313 Sarcoma Reconstruction Rio Mar 9 314 Pediatric Microsurgery Rio Mar 10

9:15am - 10:40am Concurrent Scientific Paper Presentations C-1 Rio Mar 6

9:15am - 10:40am Concurrent Scientific Paper Presentations C-2 Caribbean 2 & 3

10:40am - 11:00am Break Rio Mar Atrium

11:00am - 12:00pm President’s Invited Speaker: Ronald M. Zuker, MD, FRCSC, FACS, FAAP Rio Mar 6

12:00pm - 12:10pm “What’s New at the Meeting” Rio Mar 6

12:15pm - 1:00pm ASRM Business Meeting (Members Only) Rio Mar 6

1:00pm - 5:15pm Composite Tissue Allotransplantation Update Session Caribbean 2 & 3

4:00pm - 5:00pm ASRM Council Meeting Board Room

8:00pm - 10:00pm Meeting Services Rio Mar Atrium

8:30pm - 10:30pm Branford Marsalis Jazz Charity Concert Rio Mar 6

76 309 Prefabrication of Flaps ASRM Flap prefabrication and prelamination are advanced methods of reconstruction for complex defects in the Monday, January 15, 2007 head and neck. An update and comparison of these methods will be provided. 6:00am – 7:00am Continental Breakfast J. Baudet, MD Julian J. Pribaz, MD Robert L. Walton, MD, FACS 7:00am – 2:00pm Patient Safety Computerized Presentations Computerized patient safety modules will be avail- 310 CPT Coding and Reimbursement able throughout the meeting for individual use Recommendations on how to code procedures to (1 CME hour each). In addition to the CME received maximize reimbursement. Also, update on new for meeting attendance, these modules will allow codes for CPT 2007. attendees to increase the designated patient safety Keith E. Brandt, MD CME received. Daniel J. Nagle, MD 311 Management of Chronic Pain 7:00am – 8:00am Instructional Courses Nonoperative and operative management of neuro- pathic pain. 301 Refinements in Mandible Reconstruction David T. W. Chiu, MD This course will give practical details and innovations A. Lee Dellon, MD to optimize jaw reconstruction both from the Robert Spinner, MD functional and aesthetic standpoint of view. Peter G. Cordeiro, MD 312 Management of the Ischemic Upper Extremity Giorgio DeSantis, MD This course addresses condition causing upper Howard N. Langstein, MD extremity ischemia, such as Raynaud syndrome, chronic renal dialysis and emboli with emphasis on 302 Foot and Ankle Reconstruction current surgical evaluation and management. Free tissue transfer is always a considerable option for James Patrick Higgins, MD resurfacing extensive foot and ankle defect. Either Wyndell H. Merritt, MD muscle or skin flap has been successfully reconstruct- William C. Pederson, MD ed the dorsal and plantar soft tissue loss. Regarding 313 Sarcoma Reconstruction that the traumatized foot and ankle may have (1) Algorithms for long bone and articular reconstruc- secondary deformaties, such as chronic osteomyelics, tions for bone sarcoma and (2) soft tissue sarcoma subluxation, dislocation, metatarso phalangeal joint reconstruction to also include management of dorsal contracture, a pliable skin flap will be preferred. complications and recurrent disease. Local sensate durable flap can afford a glabrous skin Joseph J. Disa, MD flap for managements of troplic ulcer. Eyal Gur, MD Chih-Hung Lin, MD Geoffrey L. Robb, MD Lawrence B. Colen, MD Hans-Ulrich Steinau, MD 314 Pediatric Microsurgery To overview the current treatment of vascular 303 Treatment of the Mutilated Hand injuries, undescended testes and facial deformations. Immediate and post traumatic reconstruction after Gregory M. Buncke, MD mutilating hand injuries; strategies and treatment Jeffrey D. Friedman, MD options. Luis Scheker, MD Gunter Germann, MD Ronald M. Zuker, MD, FRCSC Michael W. Neumeister, MD 9:15am - 10:40am SCIENTIFIC PAPER Michael Saubier, MD, PhD PRESENTATIONS SESSION C-1 Eduardo Zancolli, III, MD *Designates resident/fellow paper presentations 304 Esophageal Reconstruction Moderators: Lawrence Gotlieb, MD Hung-Chi Chen, MD Lawrence J. Gottlieb, MD Joan E. Lipa, MD, MSc, FRCS

305 Microsurgical Salvage of Breast Reconstruction 9:15am – 9:18am Microsurgical solutions to failed implant and tissue *A New Composite Tissue Allograft Transplantation Model for Reconstruction breast reconstructions. of the Head and Neck Defects and Long Term Survival Permitted by Donor Pierre M. Chevray, MD, PhD Specific Chimerism Under Low Dose Cyclosporine A Treatment Neil A. Fine, MD, FACS Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Michael R. Zenn, MD Yalcin Kulahci; Aleksandra Klimczak; Maria Siemionow

306 Microsurgical Research and Funding 9:18am – 9:21am Presentation of available models for microsurgical *Potential Approaches to Face Harvest for Face Transplantation research. Discussion of options for funding and Institution where the work was prepared: Duke University Medical Center, Durham, research. NC, USA Gregory R. D. Evans, MD, FACS Alessio Baccarani, MD; Keith E. Follmar; Jeffrey R. Marcus; Detlev Erdmann; L. Zoe Dailliana, MD Scott Levin William A. Zamboni, MD 307 Facial Reanimation 9:21am – 9:24am David Chwei-Chin Chuang, MD Coronal-Posterior Approach for Facial/Scalp Flap Harvesting in Preparation for Marcus C. Ferreira, MD Facial Transplantation Ronald M. Zuker, MD, FRCSC Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Yalcin Kulahci; Maria Siemionow; Frank Papay; Risal Djohan; Warren Hammert; 8:00am – 8:30am Past President’s Breakfast Mark Hendrickson; James Zins (by invitation only) 9:24am – 9:27am 8:00am – 9:00am Instructional Courses *Donor/Recipient Compatibility and Morphological Outcomes of Face 308 Microsurgical Breast Reconstruction Transplantation: a Cadaver Study Review of free TRAM, DIEP and SGAP outcomes. Institution where the work was prepared: Duke University Medical Center, Durham, Elisabeth K. Beahm, MD, FACS NC, USA Ming Huei Cheng, MD Alessio Baccarani, MD; Keith E. Follmar; Raja R. Das; Srinivasan Mukundan; Jeffrey Maurice Nahabedian, MD R. Marcus; L. Scott Levin; Detlev Erdmann

77 9:27am – 9:35am 10:14am – 10:20am Discussion Discussion

9:35am – 9:38am 10:20am – 10:23am *Role of Graft-Derived Dendritic Cells in Skin Allograft Acceptance in Long-Term Follow-up of Total Penile Reconstruction with Sensate Hemifacial Allograft Transplant Model Osteocutaneous Free Fibula Flap in 23 Biological Male Patients Institution where the work was prepared: The Cleveland Clinic Foundation, Institution where the work was prepared: Gulhane Military Medical Academy. Cleveland, OH, USA Depart. of Plastic Surgery, Ankara, Turkey Aleksandra Klimczak, PhD; Galip Agaoglu; Sakir Unal; Maria Siemionow Mustafa Sengezer, Professor; Serdar Ozturk; Mustafa Deveci; Fatih Zor

9:38am – 9:41am Functional Study of Motor and Sensory Recover of Facial Allotransplantation. 10:23am – 10:26am Experimental Study in Rats Adult and Children Total Phalloplasty Institution where the work was prepared: Clinica Aston, Valencia, Spain Institution where the work was prepared: Clinical Center of Serbia, Belgrade, Serbia Pedro C. Cavadas, MD, PhD; Luis Landin and Montenegro Marko Bumbasirevic, MD, PhD; Miroslav Djordjevic, MD, PhD; Sava Perovic, MD, 9:41am – 9:44am PhD Hindlimb osteomyocutaneous flap can create mixed chimerism and donor-spe- cific tolerance to composite tissue allotransplantation with the nonmyeloabla- tive conditioning in rats 10:26am – 10:30am Institution where the work was prepared: Department of Plastic and Discussion Reconstructive Surgery, Chang Gung Mem, Taipei, Taiwan Wei-Chao Huang, MD; Jeng-Yee Lin; Chung-Rong Ho; Yu-Hsuan Hsieh; Nai-Jen 10:30am – 10:33am Chang; Fu-Chan Wei *Lymph Node Transfer for Treating Mild to Moderate Lymphoedama Institution where the work was prepared: E-Da Hospital, Kaohsiung, Taiwan 9:44am – 9:50am Victoria Rose, MBBS, MD, FRCSpl; Guan-Ming Feng; Samir Mardinis; Hung-Chi Discussion Chen

9:50am – 9:53am Nerve Regeneration Through Nerve Autografts and Cold Preserved Allografts 10:33am – 10:36am Using Tacrolimus (FK506) in a Facial Paralysis Model: a Topographical and *Microdialysis is a Reliable Tool for Surveillance of Free Muscle Flaps Neurophysiological Study in Monkeys Institution where the work was prepared: Department of Plastic Surgery, Aarhus, Institution where the work was prepared: Clínica Universitaria, Universidad de Denmark Navarra, Pamplona, Spain Hanne Birke Sørensen; Gete Toft; Jens Bengaard Cristina Aubá, MD, PhD; Bernardo Hontanilla, MD, PhD; Juan Arcocha; Oscar Gorría 10:36am – 10:40am Discussion 9:53am – 9:56am The Possibility to Use Laterally-sprouting Axons at The Nerve Repaired Site as 9:15am – 10:40am SCIENTIFIC PAPER Motor Sources to innervate a Functioning Free Muscle Transplantation (FFMT) - Study in Rats PRESENTATIONS SESSION C-2 Institution where the work was prepared: Chang gung memorial hospital, Taipei, *Designates resident/fellow paper presentations Taiwan C.K. Tsao; David CC Chuang; Rong-Kuo Lyu; Shih-Ming Jung Moderators: Nicholas B. Vedder, MD William Zamboni, MD 9:56am – 9:59am The Effect of VEGF Gene Therapy and Hyaluronic Acid Enriched 9:15am – 9:18am Microenvironment on Peripheral Nerve Regeneration A New Concept of Cell-Based Immunotherapy with Chimeric Cells for Institution where the work was prepared: Gulhane Military Medical Academy, Acceptance of Composite Tissue Allograft Transplants Ankara, Turkey Institution where the work was prepared: The Cleveland Clinic Foundation, Fatih Zor; Mustafa Deveci; Abdullah Kilic; Fatih Ozdag; Bulent Kurt; Serdar Cleveland, OH, USA Ozturk; Mustafa Sengezer Maria Siemionow, MD, PhD; Aleksandra Klimczak; Yalcin Kulahci; Galip Agaoglu; Anna Jankowska 9:59am – 10:05am Discussion 9:18am – 9:21am 10:05am – 10:08am *Intrajejunal Administration of Fresh Donor Splenocytes Significantly Delays Four Dimensional CT-Scan Analysis of the Anterolateral Thigh Flap Perforator the Onset of Rejection of Heterotopic Hindlimb Composite Tissue Branching Pattern Allotransplants in Rats Institution where the work was prepared: UT Southwestern Medical Center, Dallas, Institution where the work was prepared: Department of Plastic Surgery, Chang TX, USA Gung Memorial Hospital, Taipei, Taiwan Michel Saint-Cyr, MD; Gary Arbique, PhD; Jean Gao, PhD; Dan Hatef, MD; Christopher Glenn Wallace, MB, ChB, MRCS; Chia-Hung Yen, PhD; Hsiang-Chen Spencer Brown, PhD; Rod Rohrich, MD Yang, MSc; Chun-Yen Lin, MD, PhD; Ren-Chin Wu, MD; Wei-Chao Huang, MD, PhD; Fu-Chan Wei, MD, FACS

10:08am – 10:11am The Supero-lateral Leg (SLL) Flap: an Anatomical Study and Clinical 9:21am – 9:24am Applications *Perfusing with Anti-Alpha-Beta-T Cell Receptor Monoclonal Antibody in Institution where the work was prepared: University of Sao Paulo, Sao Paulo, Brazil Composite Osteomyocutaneous Tissue Allotransplantation Avoids Graft- Hsiang Wei Teng; Luciano Ruiz Torres; Arnaldo Valdir Zumiotti Versus-Host Disease in the Lethally Irradiated Recipient Rats Institution where the work was prepared: Chung Rong Ho, Tao-yuan, Taiwan 10:11am – 10:14am Chung-Rong Ho, MD; Wei-Chao Huang, MD; Jeng-Yee Lin; Nai-Jen Chang; Yu- Clinica Application of the Free Microdissected Thin Groin Flap Hsuan Hsieh; Fu-Chan Wei Institution where the work was prepared: Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Kanagawa, Japan 9:24am – 9:33am Naohiro Kimura, MD, PhD Discussion

78 9:33am – 9:36am 10:18am – 10:27am *Fludarabine Facilitates the Nonmyeloablative Strategy and Creation of Mixed Discussion Chimerism to Induce Immune Tolerance to Composite Tissue Allograft Institution where the work was prepared: Chang Gung Memorial Hospital, 10:27am – 10:30am Tayoyuan, Taiwan The Differential Effects of Isoflurane and Propofol on Free Tissue Transfer Jeng-Yee Lin, MD; Wei-Chao Huang; Chung-Rong Ho; Fu-Chan Wei; David CC Ischemia-Reperfusion Injury-- A Genomic Analysis Chuang; Ming-Huei Cheng Institution where the work was prepared: University of Utah, Salt Lake City, UT, USA 9:36am – 9:39am Marga F. Massey, MD; Kevin J. Bruen, MD; Dhanesh K. Gupta, MD *Rapamycin-Treated Alloantigen-Pulsed Host Dendritic Cells for the Induction of Hind-Limb Allograft Survival Institution where the work was prepared: University of Pittsburgh Medical Center, 10:30am – 10:33am Pittsburgh, PA, USA *Wound Healing Outcomes Following Pre-operative and Justin Michael Sacks, MD; Ryosuke Ikeguchi; Jignesh Unadkat; Elaine Horibe; Limb Surgery for Soft Tissue Sarcoma Linda Lu; W.P. Andrew Lee; Maryam Feili-Hariri Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA Pankaj Tiwari, MD; Gurminder Singh, BA; Patrick Hsu, MD; Oluseyi Aliui, BA; 9:39am – 9:45am Charles E. Butler, MD; Howard N. Langstein, MD Discussion

9:45am – 9:48am 10:33am – 10:40am Size Limits in Autologous Cell-based Ectopic Prefabrication of Engineered Discussion Bone Flaps in Rabbits Institution where the work was prepared: University Hospital Basel, Basel, Switzerland 10:40am – 11:00am Break Oliver Scheufler, MD; Dirk J. Schaefer, MD; Claude Jaquiery, MD; Alessandra Braccini, PhD; David J. Wendt, PhD; Juerg A. Gasser, PhD; Peter Ingold, PhD; Gerhard Pierer, MD, PhD; Michael Heberer, MD, PhD; Ivan Martin, PhD 11:00am – 12:00pm President’s Invited Speaker: Ronald M. Zuker, MD, FRCSC, FACS, FAAP 9:48am – 9:51am *Inside-Out Tissue Engineering: Using Explanted Microcirculatory Beds for Generating Vascularized Neo-Livers Institution where the work was prepared: Stanford University, Stanford, CA, USA Robert G. Bonillas, MD; Cynthia Hamou; Daniel J. Ceradini, MD; Shahram Aarabi; Turtles and Challenges: A Survival Guide for the Geoffrey Gurtner Young Microsurgeon Microsurgery need not be survival of the fittest. 9:51am – 9:57am Around every bend lie opportunities to embrace, Discussion major challenges to solve and first smiles to enjoy. We will also look at 7 microsurgical areas of accom- 9:57am – 10:00am plishment and outline 7 more emerging areas *De Novo Bone Formation by Adult Adipose Derived Stem Cells in for the young microsurgeon to explore. Enjoy the Prefabricated Vascularized Capsules in Rats journey! Institution where the work was prepared: Southern Illinois University School of Ronald Zuker received his MD degree from the Medicine, Springfield, IL, USA University of Toronto in 1969, followed by a rotating Minh-Doan Nguyen, MD; Hans Suchy; Jagadish Hegde; Chris Chambers; Michael internship in Vancouver, BC. After a brief period of Neumeister family practice he pursued an interest in Anthropology and Jungle Medicine, spending one year working with 10:00am – 10:03am the Shipibo Indians in the Amazon basin – eastern Involvement of Notch1 in Osteoinduction of Adipose Derived Adult Stem Cells Peru. He then entered the McGill University program in Institution where the work was prepared: Southern Illinois University, Springfield, Surgery and returned to the Gallie Program at the IL, USA University of Toronto to obtain his FRCSC in Damon Cooney, MD, PhD; N. Berry; Christopher Chambers; MW Neumeister Plastic Surgery. He received a McLaughlin Travelling 10:03am – 10:09am Fellowship to pursue interests in microvascular surgery Discussion and pediatric plastic surgery, where he spent most of his time in Japan under the guidance of Dr. Kiyonori 10:09am – 10:12am Harii and also in New Zealand, Australia and Europe. *In Vivo Down-Regulation of Vascular Endothelial Growth Factor (VEGF) Upon returning to Canada he joined the staff of The Protein in a Gracilis Muscle Model Using siRNA Hospital for Sick Children as a consultant in Plastic Institution where the work was prepared: University of Nevada School of Medicine, Surgery and as Director of the Burn Unit. He was later Las Vegas, NV, NV, USA appointed to the Department of Surgery of the Peter Robert Letourneau, MD; Farhad A.amiri; Linda L. Stephenson, BS, MT; Wei University of Toronto as a lecturer in surgery, and now Z. Wang, MD; William A. Zamboni, MD serves as Full Professor. As a staff surgeon of the Division of Plastic Surgery at The Hospital 10:12am – 10:15am for Sick Children, Dr. Zuker practices plastic and Effects of Hyperbaric Oxygen on the Survivability of the Replanted Hindlimb reconstructive surgery exclusively in children. His Subjected to Prolonged Warm Ischemia primary interest is in facial paralysis and is the Institution where the work was prepared: William Beaumont Army Medical Center, recognized worldwide authority for this disorder. Dr. El Paso, TX, USA Zuker is co-director of the University of Toronto Christopher J. Salgado, MD; Juan A. Ortiz, MD; Samir Mardini, MD; Hung-Chi Facial Paralysis Clinic which is the only one of its kind Chen, MD, FACS; Raoul Gonzales, DVM; James R. Little, MD in Canada. 10:15am – 10:18am *Efficacy of Intravenous and Intraosseous Donor Bone Marrow Transplantation 12:00pm – 12:10pm “What’s New at the Meeting” in Chimerism Induction on Vascularized Skin Allograft Transplants Peter C. Neligan, MD Institution where the work was prepared: The Cleveland Clinic Foundation, Cleveland, OH, USA Aleksandra Klimczak, PhD; Sakir Unal; Maria Siemionow 12:15pm – 1:00pm ASRM Business Meeting (Members Only)

79 1:00pm – 5:15pm Composite Tissue Allotransplantation Update Session The 6th International CTA Symposium in Tuscon, Arizona in January, 2006 brought together many leaders in Transplant and Reconstructive Microsurgery. Join us for another exciting conference that brings together leaders in transplant, immunosuppres- sion and tolerance for a look at CTA today and in the future. Course is complimentary to ASRM registrants, but pre-registration is required

1:00pm – 1:15pm Welcome and Introduction Warren C. Breidenbach, MD

1:15pm – 1:30pm Duke University’s Research Program and How it Relates to CTA L. Scott Levin, MD

1:30pm – 2:30pm Panel: Strategies for Reducing the Risk of Immunosuppression in CTA Linda C. Cendales, MD Suzanne T. Ildstad, MD Joseph R. Leventhal, MD, PhD Si M. Pham, MD, FACS

2:30pm – 3:30pm Panel: Status of CTA Around the World Warren C. Breidenbach, MD Jean-Michel Dubernard, MD, PhD Marco Lanzetta, MD David M. Levi, MD Raimund Margreiter, MD Maria Z. Siemionow, MD, PhD

3:30pm – 3:45pm Break 3:45pm - 4:00pm Translating CTA: Where Now From Here Linda C. Cendales, MD

4:00pm – 5:15pm Abstract Presentations

4:00pm - 5:00pm ASRM Council Meeting

8:30pm – 10:30pm ASRM Concert Event

Branford Marsalis Jazz Charity Concert Experience a once-in-a-lifetime music event featuring one of the most popular jazz artists of our time. In a very limited, intimate setting at the Westin, Grammy Award winning saxophonist Branford Marsalis will perform for ASRM to benefit Habitat for Humanity’s Musicians’ Village. The devastation caused by Hurricane Katrina forced many of New Orleans’ musicians to flee the city. The Musicians' Village, an effort co-chaired by Marsalis, has endeavored to build 81 Habitat-con- structed homes in the Upper Ninth Ward for displaced New Orleans musicians. Learn more about this accomplished artist and the project at www.branfordmarsalis.com. This ticket is for a charitable event sponsored by the ASRM a 501(c) 3 not for profit organization. Net proceeds from this event will be contributed to The New Orleans Habitat Musicians’ Village. The ASRM would like to thank Smith and Nephew for their generous co-sponsorship of this event. See page 16 for ticket information.

80 ASRM DAY-AT-A-GLANCE Tuesday, January 16, 2007

6:00am - 7:00am Continental Breakfast Rio Mar Foyer & Ocean Terrace

6:30am - 11:00am Speaker Ready Room San Cristobal

6:30am - 12:00pm Meeting Services Rio Mar Atrium

7:00am - 8:00am Instructional Courses 315 Perforator Flaps Rio Mar 2 316 Genitourinary Reconstruction Rio Mar 3 317 Immunology Update Rio Mar 4 318 Incorporating Aesthetic Surgery in Your Microsurgery Practice Rio Mar 7 319 Vascularized Bone Flaps Rio Mar 8 320 Non-Microsurgery for the Microsurgeon Rio Mar 9 321 Trunk and Chest Reconstruction Rio Mar 10

8:15am - 9:00am Concurrent Scientific Paper Presentations D-1 Rio Mar 6

8:15am - 9:00am Concurrent Scientific Paper Presentations D-2 Caribbean 2 & 3

9:10am - 10:10am Panel: Optimizing Results in Head & Neck Reconstruction Rio Mar 6

10:10am - 10:30am Break Rio Mar Foyer

10:30am - 11:30am Panel: Facial Transplantation - Where are we Headed? Rio Mar 6

11:30am - 11:38am ASRM Military Liaison Rio Mar 6 Microsurgery Mission Initiative

11:38am - 12:38pm Buncke Lecturer: James Urbaniak, MD Rio Mar 6

1:00pm - 3:00pm Narakas Society Guest Panel Rio Mar 6

3:00 Meeting Adjourned

81 8:18am – 8:21am ASRM Oral function reconstruction by vascular fibular bone flap simultaneous dental Tuesday, January 16, 2007 implants-12 years experience in Chang Gung Memorial Hospital Institution where the work was prepared: Chang-Gang Memorial Hospital, Taipei, Taiwan 6:00am – 7:00am Continental Breakfast Yang-Ming Chang, DDS; F.C. Wei

7:00am – 8:00am Instructional Courses 8:21am – 8:24am Long-term Subjective and Objective Outcome after Primary Repair of 315 Perforator Flaps Traumatic Facial Nerve Injuries Phillip Nicholas Blondeel, MD Institution where the work was prepared: Erasmus Medical Center Rotterdam, Steven Morris, MD Rotterdam, Netherlands Fu-Chan Wei, MD, FACS Marc A.M. Mureau; Erik Frijters; Stefan O.P. Hofer

316 Genitourinary Reconstruction The use of microsurgery in the solution of complex 8:24am – 8:30am genitourinary problems will be reviewed. Topics Discussion include the management of post-traumatic vascular insufficiency, post-prostalectomy cavernous nerve reconstruction and complex 8:30am – 8:33am congential acquised pelvic deformities. Prefabrication of Trachea for the Reconstruction of Hemilaryngectomy Defects Lawrence B. Colen, MD in Unilateral Laryngeal Cancer Gerald Jordan, MD Institution where the work was prepared: KUL Leuven University Hospitals, Leuven, Belgium 317 Immunology Update Jan Jeroen Vranckx, MD; V. Vanderpoorten, MD, PhD; G Fabre; M Vandevoort; P. The course will present basic aspects of immunoiog- Delaere ical responses to transplantation of composite tissue allografts (CTA’s). Strategies to prevent graft rejection will be outlined as well as side effects on immuno- 8:33am – 8:36am suppressive . Future approaches in Prelamination of Radial Forearm Fascia Flaps for the Treatment of Trachea transplantation of CTA’s will be discussed. Re-stenosis W.P. Andrew Lee, MD Institution where the work was prepared: KUL Leuven University Hospitals, Leuven, Maria Siemionow, MD, PhD Belgium R. Vertriest, MD; JJ Vranckx, MD; MD.,PhD Vanderpoorten; G Fabre; M 318 Incorporating Aesthetic Surgery in Your Vandevoort; P. Delaere, MD, PhD Microsurgery Practice Highlight the mechanisms available to enhance one’s micro-surgical practice with Aesthetic Surgery. Tips and insights. 8:36am – 8:40am Joseph M. Serletti, MD, FACS Discussion Jeffrey D. Friedman, MD

319 Vascularized Bone Flaps 8:40am – 8:43am Allen T. Bishop, MD *Comparison Between Anterolateral Thigh Flap and Free Radial Forearm Flap Konstantinos N. Malizos, MD For Hypopharyngeal Defect Reconstruction Satoshi Toh, MD Institution where the work was prepared: Chang Gung Memorial Hospital, Kaohsiung, Taiwan 320 Non-Microsurgery for the Microsurgeon Johnson C. Yang, MD; Seng-Feng Jeng; Yur-Ren Kuo; Ching-Hua Hsien Christopher Attinger, MD Detlev Erdmann, MD George Psaras, MD 8:43am – 8:46am Extended Left Colon Interposition for Esophageal Reconstruction Using Distal 321 Trunk and Chest Reconstruction End Supercharge Procedure This talk will encompass esthetic breast reconstruc- Institution where the work was prepared: Chang Gung Memorial Hospital- tions, chest wall reconstructions due to various kinds Kaohsiung Medical Center, Kaohsiung, Taiwan of malignancies, radiation necrosis, exposure of Yur-Ren Kuo, MD, PhD, FACS; Nai-Siong Kueh; Hung-I Lu; Chih-Yen Chien heart, lung or aorta, microvascular sternal turnover for intractable tunnel chest, abdominal wall reconstructions for exposed viscera, and reconstruc- tion for exposed spine, etc. 8:46am – 8:49am Charles E. Butler, MD Swallowing Outcomes after Microvascular Head and Neck Reconstruction: A Yueh-Bih Tang Chen, MD, PhD Prospective Review of 191 Cases Lawrence J. Gottlieb, MD Institution where the work was prepared: Cleveland Clinic Foundation, Cleveland, OH, USA Samir Khariwala; Prashant Vivek; Ramon Esclamado, MD; Benjamin Wood; Robert 8:15am – 9:00am SCIENTIFIC PAPER Lorenz; Marshall Strome; Daniel Alam, MD PRESENTATIONS SESSION D-1 *Designates resident/fellow paper presentations 8:49am – 8:52am Moderators: Navin Singh, MD Comparison Between Jejunum and Ileocolon Flaps in Terms of the Risk of Food Peirong Yu, MD Aspiration after Voice Reconstruction Institution where the work was prepared: E-Da Hospital, Kaohsiung, Taiwan 8:15am – 8:18am Hung-Chi Chen, MD, FACS; Yueh-Bih Tang, MD, PhD; Samir Mardini, MD; Pediatric Mandibular Reconstruction with the Vascularized Fibula Flap: A Christopher Salgado Long-term Evaluation of Outcomes Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA 8:52am – 9:00am Melissa A. Crosby, MD; Jack W. Martin; Geoffrey L. Robb, MD; David W. Chang Discussion

82 8:15am – 9:00am SCIENTIFIC PAPER 8:50am – 8:53am PRESENTATIONS SESSION D-2 *New Method for Real-Time Muscle Flap Viability Monitoring Institution where the work was prepared: Chaim Sheba Medical Center, Tel Aviv, Israel *Designates resident/fellow paper presentations Benjamin Meilik, MD; Batia Yafe, MD; Arie Orenstain, MD, Profesor

Moderators: Charles Butler, MD 8:53am – 8:56am Treatment of Symptomatic Diabetic Peripheral Neuropathy by Surgical Michael Neumeister, MD Decompression of Three Peripheral Nerves Institution where the work was prepared: Peking Union Medical College, Beijing, China Yong Yao, MD; R-Z. Wang, MD 8:15am – 8:18am Effect of Cooling on Vascular Alpha-Adrenergic Receptor-Mediated Responses 8:56am – 9:00am in Primate Digital Arteries Discussion Institution where the work was prepared: Wake Forest University School of 9:10am – 10:10am Panel: Optimizing Results in Head and Neck Medicine, Winston-Salem, NC, USA Reconstruction Delrae M. Eckman, PhD; Mamta Fuloria, MD; Michael F. Callahan, PhD; Suzanne Panel will discuss tracks and approaches to optimize E. Watt; Janice D. Wagner, DVM, PhD; Thomas L. Smith, PhD; L. Andrew Koman, outcome and minimize donor morbidity. MD Peter C. Neligan, MD, Moderator Ralph Gilbert, MD Ron Yu, MD 8:18am – 8:21am 10:10am – 10:30am Break with Exhibitors *Ethyl Nitrite in the Management of Microsurgical Vasospasm in a Rat Model Institution where the work was prepared: Duke University Medical Center, Durham, 10:30am – 11:30am Panel: Facial Transplantation – Where NC, USA are we headed? Alessio Baccarani, MD; Koji Yasui; Kevin C. Olbrich; Ahmed El-Sabbagh; Stephen The panel will discuss current the current status of facial Kovach; Keith E. Follmar; Detlev Erdmann; L. Scott Levin; Jonathan S. Stamler; transplantation with a presentation of advancement in experimental and clinical protocols, as well as discussion Bruce Klitzman; Michael R. Zenn of ethical and other related issues. Maria Siemionow, MD, PhD, Moderator Warren Breidenbach, MD 8:21am – 8:25am Marco Lanzetta, MD Discussion 11:30am - 11:35am ASRM Military Liaison Initiative L. Scott Levin, MD, FACS 8:25am – 8:28am Vascular Injuries in Very Small Children: An Algorithm for Diagnosis and 11:35am - 11:38am ASRM Microsurgery Mission Initiative Treatment Fred Duffy, MD Institution where the work was prepared: Texas Children Hospital, Houston, TX, USA 11:38am – 12:38pm Buncke Lecture: James Urbaniak, MD Jamal Bullocks, MD; Jeffrey D. Friedman, MD; Michael Klebuc, MD

8:28am – 8:31am A New Rat Model for Brachial Plexus Birth Injury Associated Shoulder The Harry Buncke Lectureship has been created with the support of the California Pacific Medical Center to honor Deformity Dr. Buncke's remarkable contributions fo the field of Institution where the work was prepared: Wake Forest University Health Sciences, microsurgery. Dr. Harry Buncke has played a major role Winston-Salem, NC, USA in the development of our specialty and has helped Zhongyu Li, MD, PhD; Jianjun Ma; Cathy S. Carlson, PhD; Thomas L. Smith, PhD; develop several microsurgical laboratories across the globe. He has influenced countless residents and L. Andrew Koman, MD fellows as well as numerous department chairs through- out the world. It is with great appreciation that we are 8:31am – 8:35am able to honor Dr. Harry Buncke with this lectureship due to the sponsorship of the California Pacific Medical Center. Discussion It is our pleasure to introduce James Urbaniak, MD as the 2007 Harry Buncke Lecturer. 8:35am – 8:38am The Perfect Virtue *Anatomy and Hystology of the Latissimus Dorsi Subunits for Facial A past president of the ASRM, Dr. Urbaniak is recog- Reanimation nized as a pioneer in the replantation of severed digits and hands. For the past 36 years he has conducted Institution where the work was prepared: Souza Aguiar City Hospital and Federal significant research in the area of microsurgical recon- University of São Paulo, Rio de Janeiro and São Paulo, Brazil struction of traumatized extremities and avascular necro- André Salo Buslik Hazan, MD; Fábio Xerfan Nahas, PhD, MD; Marcus Vinícius Jardini sis of the femoral head. He was one of the first medical Barbosa, PhD, MD; Eugênio Piñeda, PhD, MD; Lydia Masako Ferreira, PhD, MD researchers in the world to develop and refine these tech- niques and as a result, the principles and guidelines he established for microsurgery are widely accepted and used. 8:38am – 8:41am Dr. Urbaniak received his from Duke University School of Medicine where he completed his The Free Partial Superior Latissimus (PSL) Muscle Flap: Preservation of Donor surgical internship and orthopaedic surgery residency, and Site Form and Function eventually joined the faculty. Dr. Urbaniak is the Virginia Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, Flowers Baker Professor of Orthopaedic Surgery and USA President Elect of the International Federation of Societies Karen M. Horton, MD, MSc, FRCSC; Rudolf F. Buntic, MD; Darrell Brooks; Charles for Surgery of the Hand. K. Lee The ASRM would like to thank the California Pacific Medical Center for their generous sponsorship of this 8:41am – 8:44am Buncke Lecture. Cluster Analysis and Vascular Anatomy of the Radial Forearm Flap Cutaneous Perforators: A Cadaver Study 1:00pm - 3:00pm Narakas Society Guest Panel Institution where the work was prepared: Christine M Kleinert Institute, Louisville, The panel will focus on facts as opposed to opinion and controversies, e.g., indications, timing of nerve reconstruc- KY, USA tion, treating sequellae, etc. Mirsad Mujadzic, MD; Ruben N. Gonzalez, MD; A. Scott LaJoie, PhD, MSPH; Dan Howard M. Clarke, MD, PhD Hatef, MD; Michel Saint-Cyr, MD Alain Gilbert, MD Julia Terzis, MD, PhD Peter Waters, MD 8:44am – 8:50am Discussion 3:00pm Meeting Adjourned

83 ABSTRACT TABLE OF CONTENTS

AAHS/ASRM/ASPN Author Index ...... 85-86 AAHS Abstracts...... 87-108 AAHS Posters ...... 109-114 AAHS/ASRM/ASPN Outstanding Nerve Papers...... 115-116 ASPN Abstracts...... 117-139 ASRM Abstracts ...... 140-183

84 Carvalho, Alex ...... 94 Feng, Guan-Ming ...... 167 Jebson, Peter J. L...... 108 Author Index Cavadas, Pedro C...... 150, 163 Ferreira, Lydia Masako ...... 182 Jeng, Seng-Feng . 132, 160, 164, 170, 177, 178 Ceradini, Daniel J...... 172 Fink, BF ...... 102 Jobin, Charles M...... 134 Cetrulo Jr, Curtis L...... 158 Firoozbakhsh, Keikhosrow ...... 94, 112 Jones, Neil F...... 147 Aarabi, Shahram ...... 172 Fishman, Elliot K...... 140 Jung, Shih-Ming ...... 165 Chambers, Christopher ...... 134, 172 Adamany, Damon C...... 96 Follmar, Keith E...... 161, 162, 180 Chan, Jeff ...... 93 Adani, Roberto ...... 150 Fox, Ida K...... 134 Chang, Benjamin ...... 159 Kaarela, Outi ...... 151 Agaoglu, Galip ...... 163, 169 Freiman, Jacob J...... 147 Chang, David W...... 176 Kao, Dennis ...... 99 Agrestic, Michael ...... 99 Friedman, Jeffrey D...... 181 Chang, Hui-Hsiu ...... 117 Frijters, Erik ...... 152 Kardestuncer, Tarik ...... 94 Akelina, Yelena ...... 134 Chang, James ...... 92 Fuloria, Mamta ...... 180 Kaufman, K. R...... 123 Al-Attar, Ali ...... 127 Keirstead, Hans S...... 130 Chang, Nai-Jen ...... 164, 170 Alaid, A. O...... 123 Kelly, Jack L...... 93 Alam, Daniel ...... 179 Chang, Yang-Ming ...... 176 Gaertner, Jamie D...... 121, 135, 136 Kemp, Stephen W.P...... 136 Aldridge III, Julian McClees ...... 149 Chao, Moses ...... 129 Galaviz, Paula ...... 99 Kerns, James M...... 138 Alfonso, Israel ...... 118, 147 Chavez, Eva ...... 98, 113 Gao, Dy ...... 102 Khan, Farah Naz ...... 143, 145 Gao, Jean ...... 166 Aliui, Oluseyi ...... 175 Chen Tang, Yueh-Bih ...... 117 Khariwala, Samir ...... 179 Gasser, Juerg A...... 171 Alon, Malvina ...... 159 Chen, Constance M...... 141 Khuthaila, Dana K...... 145 Gautam, Abhinav K...... 146 Chen, Hung-Chi ...... 167, 174, 179 Kilic, Abdullah ...... 165 Amir, Aharon ...... 149 Georgescu, Alexandru ...... 94, 102 Amiri, Farhad A...... 173 Chen, Kuang-Te ...... 116 Kimura, Naohiro ...... 166 Gerhardt Summers Helena ...... 120 Kiran, Ravi ...... 98 Amrami, Kimberly K...... 87, 120, 128 Chen, Lun ...... 137 Germann, Günter ...... 106, 158 Kjellin, Ingrid ...... 107 Chen, Michael ...... 101 An, Kai-Nan ...... 87, 106 Gerostathopoulos, Nikolaos ...... 128 Klebuc, Michael ...... 153, 181 Ansorge, Heather L...... 92 Chen, Ming-Ting ...... 156 Giannoulis, Filippos S...... 95, 103 Klimczak, Aleksandra 161, 163, 169, 174 Arbique, Gary ...... 166 Chen, Shun-Sheng ...... 132 Gonzales, Raoul ...... 174 Klitzman, Bruce ...... 180 Arcocha, Juan ...... 164 Cheng, Ming-Huei ...... 155, 170 Gonzalez, Mark ...... 138 Kollender, Yehuda ...... 149 Ardelean, Filip ...... 94, 102 Cheng, Nai-Chen ...... 156 Gonzalez, Ruben N...... 183 Koman, L. Andrew ...... 150 Goodwin, Adam ...... 88 Atkinson, Denis ...... 119 Cheung, Shun-Man ...... 160 Koob, Jason W...... 121, 131, 135 Gorría, Oscar ...... 164 Atroshi, Isam ...... 97 Kosins, Aaron M...... 130 Chevray, Pierre ...... 142 Grady, M. Sean ...... 133 Kostopoulos Epaminondas ...... 151 Aubá, Cristina ...... 164 Chien, Chih-Yen ...... 179 Graif, Moshe ...... 126, 127 Kotajarvi, Brian ...... 120 Chiu, Ernest S...... 146 Greenberg, Jeffrey A...... 89 Kovach, Stephen ...... 180 Chloros, G.D...... 126, 150 Greives, Matthew R...... 158 Baccarani, Alessio ...... 150, 160, 161, 180 Kraisarin, Jirachart ...... 106 Groff, Robert G...... 133 Bach, Harold Gregory ...... 138 Chuang, Chwei-Chin . . . . 116, 149, 155, 165, 170 Krishnan, Kartik ...... 129 Bach, Joel ...... 90 Chudnovsky, Nachum ...... 127 Grossman, John. A. I...... 118 Gupta, Dhanesh K...... 175 Kryger, Gil S...... 159 Backus-Saccoliti, Sherri I...... 105 Clavero, J. A...... 140 Gur, Eyal ...... 149 Kubo, Tateki ...... 122 Badalamente, Marie ...... 91 Cobb, Tyson ...... 100, 115 Kueh, Nai-Siong ...... 179 Bae, Donald S...... 94 Gurtner, Geoffrey ...... 172 Cohen, Akiva S...... 133 Gyovai, James ...... 95 Kulahci, Yalcin . 138, 139, 161, 162, 169 Bain, James ...... 129 Kuo, Yur-Ren . 160, 165, 177, 178, 179 Bajaj, Anureet ...... 142 Colman, Matthew ...... 103 Cooney, Damon ...... 98, 173 Kurt, Bulent ...... 165 Baldini, Todd ...... 90 Hadlock, Tessa A...... 132 Kwon, Yong ...... 89 Copray, J.C.V.M...... 133 Bamberger, HB ...... 100 Haerle, Max ...... 123 Barbe, Mary F...... 99 Cordeiro, Peter G...... 141 Halvorson, Eric ...... 141 Barbosa, Marcus Vinícius Jardini ...... 182 Crosby, Melissa A...... 176 Hamdi, Moustapha ...... 145 Lai, Chao-Yi ...... 148 Barker, Allison R...... 124, 139 Cui, XD ...... 102 Hammert, Warren ...... 162 LaJoie, A. Scott ...... 183 Barnea, Yoav ...... 149 Czermak, Christoph ...... 158 Hamou, Cynthia ...... 172 Lakke, E. A. J. F...... 123 Barr, Ann E...... 99 Handy, Marcus J...... 99 Lalonde, Donald H...... 95, 98, 115 Barreto, Andre ...... 107 Hansen, Scott L...... 108 Lalonde, Janice ...... 98, 115 Baumeister, Steffen P...... 150 Dahl, William ...... 96 Harrison, Heather ...... 138 Landin, Luis ...... 163 Bayat, Ardeshir ...... 90, 112 Dai, Qiang ...... 93 Hatef, Dan ...... 111, 166, 183 Langstein, Howard N...... 175 Becker, Stefan ...... 123 Das, Raja R...... 162 Hayashi, Ayato ...... 121, 131, 135 Lannon, Declan A...... 153 Bednar, John M...... 96 Day, Joe P...... 145 Hayes, Austin G...... 134 Latta, Loren ...... 107 Belzberg, Allan J...... 137 laurentin, luis ...... 88 De Ruiter, Godard C.W...... 122, 123 Hazan, André Salo Buslik ...... 182 Bengaard, Jens ...... 168 Heaton, James T...... 132 le Cessie, S...... 119 De Santis, Giorgio ...... 150 Bengtson, Keith A...... 120 Heberer, Michael ...... 171 LeBlanc, Martin R...... 98, 115 Beredjiklian, Pedro K...... 92 Delaere, P...... 177, 178 Heckler, Matthew ...... 100 Lee, Charles K...... 147, 159, 182 Berger, Evelyn ...... 106 Dellon, A. Lee ...... 124, 139 Hegde, Jagadish ...... 172 Lee, W.P. Andrew ...... 171 Berger, Richard A...... 87, 88, 106 DeSilva, Gregory L...... 87 Heitmann, Christoph ...... 158 Lenhoff, Mark W...... 105 Berry, N...... 173 Desy, Nicholas M...... 128 Hendrickson, Mark ...... 162 Lerman, Oren Z...... 158 Bezuhly, Michael ...... 95 Deune, E. Gene ...... 96 Hentz, Vincent R...... 92 Leshem, David ...... 149 Bhuller, Amardip ...... 157 Deveci, Mustafa ...... 165, 167 Herrand, Hector ...... 147 Letourneau, Peter Robert ...... 173 Bickel, Brent A...... 96 Dhar, Sanjay ...... 130 Herrera Jr, Fernando A...... 147 Leven, Robert M...... 138 Bickel, Kyle ...... 108 Higgins, Amanda ...... 95 Levin, L. Scott ...... 89 Diaz, Veronica ...... 107 Bickels, Jacob ...... 149 Hillstrom, Howard J...... 105 Levine, Jamie P...... 158 Biernaskie, J...... 134 Diaz, Otoniel ...... 147 Hindocha, Sandip ...... 90, 112 Levine, Joshua L...... 146 Bishop, Allen T...... 102 Dietz, Klaus ...... 123 Ho, Chung-Rong ...... 164, 170 Li, Zhongyu ...... 181 Bluebond-Langner, Rachel . . .154, 155, 157 Disa, Joseph J...... 141 Hofer, Stefan O.P...... 152 Liechty, Kenneth W...... 92 Boddeke, H. W. G. M...... 133 Djohan, Risal ...... 157, 162 Hofstede-Buitenhuis, S.M ...... 119 Lifchez, Scott ...... 99 Boer, Gerard J ...... 116 Djordjevic, Miroslav ...... 167 Holden, Martha ...... 150 Lin, Cheng-Hung ...... 148 Bois, John P...... 122 Dormans, John P...... 159 Hontanilla, Bernardo ...... 164 Lin, Chih-Hung ...... 148 Bonillas, Robert G...... 172 Horibe, Elaine ...... 171 Dorsi, Michael ...... 137 Lin, Chun-Yen ...... 169 Botts, Jonathon Devlin ...... 89 Horton, Joseph ...... 87 Dosanjh, Amarjit S...... 108 Lin, Jeng-Yee ...... 170 Boviatsis, Efstathios ...... 128 Horton, Karen M...... 146, 182 Lin, Yu-Te ...... 116, 148 Doser, Michael ...... 123 Boydston, William ...... 119 Howell, Julianne ...... 95 Little, James R...... 174 Braccini, Alessandra ...... 171 Draganich, Louis ...... 103 Hsieh, Ching-Hua ...... 132 Liu, Daniel Z...... 121, 135 Bravo, Cesar J...... 102 Ducic, Ivica ...... 127 Hsieh, Yu-Hsuan ...... 164, 170 Lorenz, Robert ...... 179 Brockardt, Chad ...... 93 Dy, Christopher J...... 107 Hsien, Ching-Hua ...... 177, 178 Low, David W...... 159 Brooks, Darrell ...... 146, 182 Dyck, P.J...... 123 Hsu, Patrick ...... 175 Lu, Hung-I ...... 179 Brown, Spencer ...... 166 Huang, Jason H...... 133 Lu, Linda ...... 171 Browne, Earl ...... 157 Huang, Wei-Chao ...... 164, 169, 170 Lu, Tsu-Hsiang ...... 132 Bruen, Kevin J...... 175 Eckman, Delrae M...... 180 Huber, Christina ...... 87 Lucas, Robert M...... 150 Brunelli, Giorgio ...... 117 Edwards, Michael Charles ...... 145 Hubert, Darrin M...... 159 Lyu, Rong-Kuo ...... 165 Bueno, Reuben ...... 98 El Hassan, Bassem ...... 138 Hunter, Daniel A. . . . 121, 130, 134, 135, 136 Bullocks, Jamal ...... 181 El-Sabbagh, Ahmed ...... 180 Hurst, Lawrence ...... 91 Bumbasirevic, Marko ...... 167 Hussey, Alan ...... 129 Ma, Jianjun ...... 181 Engelstad, J.K...... 123 Buncke, Gregory M...... 147 Ma, M.S...... 133 Buntic, Rudolf F...... 146, 147, 182 Erdmann, Detlev ...... 161, 162, 180 Macheras, George ...... 128 Ikegami, Hiroyasu ...... 106 Bushnell, Brandon DuBose ...... 108 Esclamado, Ramon ...... 179 Mackinnon, Susan E. . 121, 130, 131, 134, 135, 154 Ikeguchi, Ryosuke ...... 171 Butler, Charles E...... 175 Evans, Gregory RD ...... 130, 163 Maghari, Ahmad ...... 119 Ingold, Peter ...... 171 Callahan, Michael F...... 180 Makowski, Anna-Lena ...... 107 Innocenti, Marco ...... 150 Camberos, Alfonso ...... 147 Malessy, M.J.A...... 118, 119 Capota, Irina ...... 94, 102 Fabre, Gerd ...... 144, 177, 178 Malik, Ali ...... 107 Cardenas-Mejia, Alexander ...... 116 Fahnestock, Margaret ...... 129 Jafari Saraf, Lida ...... 119 Maloney-Wilensky, Eileen ...... 133 Carlson, Cathy S...... 181 Fedorczyk, Jane M...... 99 Janevski, Peter ...... 96 Man, Li-Xing ...... 141 Carter, Timothy I...... 105 Feili-Hariri, Maryam ...... 171 Jankowska, Anna ...... 169 Manson, Paul N...... 155 Cartwright, Michael S...... 126 Feirabend, H.K.P...... 123 Jaquiery, Claude ...... 171 Marcus, Jeffrey R. . 96, 161, 162, 182

85 Mardinis, Samir ...... 167 Pusic, Andrea L...... 141 Tai, Chau Y...... 136 Zager, Eric L...... 133 Marechant-Hanson, Judith ...... 99 Randolph, Mark ...... 122 Tai, Hao-Chi ...... 156 Zamboni, William A...... 173 Martin, Ivan ...... 171 Raphael, James ...... 101 Takayama, Shinichiro ...... 106 Zaretski, Arik ...... 149 Martin, Jack W...... 176 Reddy, Sudheer ...... 92 Tang, Yueh-Bih ...... 156, 179 Zenn, Michael R...... 180 Zgonis, Miltiadis H...... 92 Masia, Jaume ...... 140 Regan, Padraic J ...... 93 Tannemaat, Martijn R...... 116 Mass, Daniel Paul ...... 103 Zhang, Jun ...... 133 Reinhart, Mary Kate ...... 90 Tay, Shian Chao ...... 87, 88 Zhang, Lin-Ling ...... 99, 125 Massey, Marga F...... 175 Ricchetti, Eric T...... 92 Teng, hsiang wei ...... 87, 88 Zins, James ...... 162 Matei, Ileana ...... 94, 102 Riley, Danny A...... 99, 125 Teplitz, Glenn Alan ...... 89 Zochodne, Douglas . . . . . 120, 136 Matloub, Hani S...... 99, 125 Rinker, Brian ...... 102 Terzis, Julia K...... 151 Zor, Fatih ...... 158, 165, 167 McAdams, Timothy R...... 92 Riordan, Colin L...... 93 Thomas, Kenneth ...... 90 Zumiotti, Arnaldo Valdir . . . . . 166 McCabe, Steven J...... 97, 110, 150 Rizzo, Marco ...... 104 Tiwari, Pankaj ...... 175 McCampbell, Beth ...... 98 Robb, Geoffrey L...... 176 McCarthy, Joseph G ...... 154 Toft, Gete ...... 168 Robinson, Kris ...... 97, 137 McConnell, Michael P...... 130 Tomita, Kazunari ...... 87, 88, 106 Roche, Nathalie ...... 145 McWilliams, Andrew ...... 108 Tong, Alice Y...... 121, 131, 135 Meek, M. F...... 133 Rochkind, Shimon ...... 126, 127 Torres, Luciano Ruiz ...... 166 Mehrara, Babak J...... 141 Rodriguez, Edgardo R...... 139 Trigg, Stephen D...... 108 Meilik, Benjamin ...... 183 Rodriguez, Eduardo D...... 154, 155, 157 Tsao, C.K...... 155, 165 Meller, Izzac ...... 149 Roesner, Harald ...... 123 Tukiainen, Erkki ...... 151 Mendoza, Charles ...... 130 Rohde, Christine ...... 110, 158 Tung, Thomas H...... 121, 131, 135, 136 Mercer, Deana ...... 94, 112 Rohrich, Rod ...... 166 Turegun, Murat ...... 158 Messer, Terry M...... 108 Rosales, Roberto S...... 97 Messina, Aurora ...... 129 Rose, Victoria ...... 167 Meyer, Richard ...... 137 Rosenberg, Zehava ...... 129 Unadkat, Jignesh ...... 171 Michalski, Bernadeta ...... 129, 136 Rosenwasser, Melvin P...... 134 Unal, Sakir ...... 163, 174 Midha, Raj ...... 134, 136 Rosson, Gedge D...... 139 Midha, Rajiv ...... 120 Roussalis, John ...... 98, 113 Van Dam, G.M...... 133 Miller, F...... 134 Rowe, David ...... 99 Van Den Berg, R.J...... 123 Milne, Edward ...... 107 Russell, Stephen M...... 129 Van Dijk, J.G...... 118, 119 Mirza, M. Ather ...... 90 Van Landuyt, Koenraad ...... 145 Mithani, Suhail K...... 154 Mitra, Amit ...... 98 S. Forootan, Kamal ...... 119 Vanderpoorten, V...... 177, 178 Mitra, Avir ...... 113 Saadeh, Pierre Boutros ...... 154 Vandevoort, Marc ...... 144, 177, 178 Molski, Michal ...... 138, 139 Sacks, Justin Michael ...... 171 Vasconez, HC ...... 102 Moneim, Moheb S...... 94, 112 Safa, Bauback ...... 159 Vega, Stephen J...... 143 Monsivais, Jose ...... 97, 137 Saing, Minn ...... 101 Vela, Luis ...... 95 Monstrey, Stan ...... 145 Saint-Cyr, Michel ...... 142, 166, 183 Verhaagen, Joost ...... 116 Moon, Wong ...... 157 Sakellarides, Harilaos ...... 100, 114 Vermeulen, Pieter ...... 144 Moradzadeh, Arash . . . 121, 130, 131, 135 Salgado, Christopher J...... 174 Vivek, Prashant ...... 179 Moran, Steven L...... 102, 104 Sanger, James R...... 99, 125 Vleggeert-Lankamp, Carmen L.A.M...... 123 Morrison, Wayne ...... 129 Sassu, Paolo ...... 148, 151 Von Gregory, Henning ...... 150 Mountcastle, Timothy S...... 146 Sato, Kazuki ...... 106 Vranckx, Jan Jeroen ...... 144, 177, 178 Mourouzis, Iordanis ...... 128 Sauerbier, Michael ...... 106 Mourouzis, Kostas ...... 128 Schaefer, Dirk J...... 171 Wagner, Janice D...... 180 Mowbray, John G...... 96 Schaller, Hans-Eberhard ...... 123 Walker, Francis O...... 126 Mueller, Hans-Werner ...... 123 Scheufler, Oliver ...... 171 Wallace, Christopher Glenn ...... 169 Mujadzic, Mirsad ...... 183 Schlosshauer, Burkhard ...... 123 Walsh, Sarah K...... 134, 136 Mukundan, Srinivasan ...... 162 Schnaar, Ronald ...... 135 Mureau, Marc A.M...... 152 Wang, Huan ...... 121, 122 Schramm, J. Mark ...... 107 Murray, Peter M...... 108 Wang, Wei Z...... 173 Schweitzer, Mark ...... 129 Musial, Joseph ...... 96 Warren, Stephen M ...... 157, 162 Schwentker, Ann ...... 119 Myckatyn, Terence M...... 121, 131, 135 Waters, Peter M...... 94 Müller, Miriam ...... 106 Segura, Roberto P...... 139 Selber, Jesse C...... 141, 143 Watkins, Barry ...... 93 Sengezer, Mustafa ...... 158, 165, 167 Watson, Stewart J...... 88, 90, 112 Nahas, Fábio Xerfan ...... 182 Serletti, Joseph M...... 141 Watt, Suzanne E...... 180 Nakamichi, Noriaki ...... 106 Serra-Hsu, Frederick James ...... 89 Wei, F. C...... 148, 155, 164, 169, 170, 176 Nakamura, Toshiyasu ...... 106 Shepard, Brandon ...... 130 Weiser, Rob W...... 89, 95, 103 Nalbantis, Emilios ...... 158 Shin, Alexander Y...... 104 Weiss, Jerry ...... 149 Neligan, Peter C...... 153 Shin, Hae W...... 126 Wendt, David J...... 171 Nelson, Cory Oliver ...... 89 Shlitner, Tzvi ...... 127 Whitlock, Elizabeth L...... 130 Neumeister, Michael W ...... 98, 172 Siddiqui, Aamir ...... 96 Wiesler, Ethan R...... 126 Nguyen, Minh-Doan ...... 172 Siebert, John W ...... 154 Williams, Christopher G...... 140 Nguyen, Minhthy ...... 107 Siemionow, Maria . . . 138, 139, 161, 162, 163, 169, 174 Windebank, Anthony J...... 121, 122, 123 Nichols, Christopher M...... 135 Singh, Gurminder ...... 175 Winograd, Jonathan M...... 122 Novak, Christine B...... 153 Singh, Navin K...... 140, 157 Wolf, Jennifer Moriatis ...... 90 Ntallas, Dimitrios ...... 128 Singh, Sunil P ...... 154 Wolfe, Scott W...... 105 Nunley, James A...... 149 Wolff, Aviva L...... 105 Nuñez, MD, Marcos ...... 147 Sinis, Nektarios ...... 123 Slater, Robert R...... 105 Wolfs, J. F. C...... 123 Smith, Douglas H...... 133 Wong, Andrew S...... 108 Okuyama, Noriko ...... 106 Smith, Thomas L...... 180, 181 Wongworawat, Montri D...... 93, 107 Olbrich, Kevin C...... 180 Sobky, Kareem ...... 90 Wood, Benjamin ...... 179 Orenstain, Arie ...... 183 Sonnad, Seema ...... 143 Wu, Liza C...... 142 Ortiz, Juan A...... 174 Sorenson, Eric J...... 121, 122, 123 Wu, Ren-Chin ...... 169 Oser, Craig ...... 96 Soslowsky, Louis J...... 92 Wurapa, Raymond K...... 96 Ouellette, E. Anne ...... 107 Sotereanos, Dean G...... 95, 103 Ozdag, Fatih ...... 165 Sparkes, Gerald ...... 95 Ozturk, Serdar ...... 158, 165, 167 Xu, Qing Gui ...... 120 Spears, Julie ...... 98, 113 Pan, Chun-Hao ...... 149 Spector, Jason ...... 154 Pansy, Brian ...... 105 Spiegel, Aldona J...... 143, 145 Yafe, Batia ...... 183 Pantos, Constantinos ...... 128 Yan, Yuhui ...... 99 Papakostas, Ioannis ...... 128 Spinner, Robert J. 120, 121, 122, 123, 128 Papay, Frank ...... 162 Stamler, Jonathan S...... 180 Yan, Ji-Geng ...... 125 Park, Julie E...... 155 Stanley, John K...... 90, 112 Yang, Hsiang-Chen ...... 169 Pego, Ana P...... 123 Steck, Jerome K...... 125 Yang, Johnson C...... 178 Perovic, Sava ...... 167 Stephenson, Linda L...... 173 Yang, lynda JS ...... 135 Pfister, Bryan J...... 133 Sterbank, PA-C, Patrick T ...... 100, 115 Yao, Yong ...... 183 Pierer, Gerhard ...... 171 Strome, Marshall ...... 179 Yasui, Koji ...... 180 Pihur, Vasyl ...... 97 Suchy, Hans ...... 172 Yaylali, Ilker ...... 118 Pinelli, Massimo ...... 150 Sullivan, Lawrence G...... 93 Yazici, Ilker ...... 138, 139 Piñeda, Eugênio ...... 182 Swafford, Albert R...... 104 Yen, Chia-Hung ...... 169 Pondaag, Willem ...... 118, 119 Sørensen, Hanne Birke ...... 168 Yin, Jir-Wen ...... 177

86 AAHS Concurrent Scientific Paper Session 1A

In-vivo 3-D Distal Radioulnar Joint Arthrokinematic Analysis During Resisted Active Pronation and Supination Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Kazunari Tomita, MD; Shian Chao Tay, MBBS, FRCS, FAMS; Richard A. Berger, MD, PhD; Kimberly Amrami; Kai-Nan An, PhD; Mayo Clinic

Purpose: Torque production is felt to be a critical function of the human forearm, yet there are no studies that have quantified displacement of the distal radioulnar joint (DRUJ) resulting from resistance rotation loading of the forearm. The purpose of this study is to quantify displacement of the DRUJ in normal subjects during resisted rotation loading.

Methods: Ten normal volunteers without any wrist pathology (age 29.2±7.4 yrs, F:5 M:5) participated in the study. Bilateral 3-D CT scans of the subjects’ distal fore- arms were obtained while grasping vertical posts of a custom jig, maintaining a neutral forearm position. Scanning was then performed in three loading con- ditions: no load (NL) serving as the control condition, maximum active resisted supination (S), and maximum active resisted pronation (P). Using Matlab and ANALYZE programs, three different registration methods (manual, automatic voxel, and automatic surface) of CT image were used to quantify relative displace- ment of the radius and ulna (designating the radius as the stabilized bone). The ulnar fovea served as the moving reference landmark where a displacement vector between loading conditions was determined using the registration matrices. Comparisons of 3-D displacement data were performed between no load and resisted pronation (NL-P), and no load and resisted supination (NL-S).

Results: The mean magnitudes of displacements in the NL-P condition were 2.51mm (±0.77mm) by manual, 2.76mm (±0.78mm) by voxel and 2.63mm (±1.23mm) by surface registration methods. The mean magnitudes of displacements in the NL-S condition were 1.65mm (±0.89mm) by manual, 2.19mm (±0.71mm) by voxel and 1.78mm (±0.73mm) by surface registration methods. No statistically significant differences were detected between the displacements in the NL-P and NL- S conditions or between the three registration methods. Relative to the images with the radius stabilized, resisted pronation load results in distal and supina- tion displacement of the images of the ulna, while resisted supination load results in relative pronation of the ulna (Fig 1).

Conclusions: 3-D displacement of the ulna relative to the fixed radius at the DRUJ during resisted rotation loading was reported in normal volunteers. The normative data from this study will contribute to understanding the normal kinematics of the DRUJ.

The Effect of Wide Excision of the Distal Ulna on Radioulnar Load-Sharing Institution where the work was prepared: Wayne State University, Department of Orthopaedic Surgery, Detroit, MI, USA Gregory L. DeSilva, MD; Joseph Horton, MD; Christina Huber, MS; Wayne State University / Detroit Medical Center Background: Previous studies have investigated the effect of wide excision of the distal ulna with regards to functional outcomes and pain relief. Likewise, studies evaluat- ing changes in radioulnar load sharing with forearm positioning and the role of the interosseous membrane have been performed. However, to our knowledge no studies have been conducted to evaluate the effects of wide excision of the distal ulna with respect to radioulnar load sharing proximal to the interosseous membrane. Methods: 5 pairs of cadaveric upper limbs (10 total) were potted into custom test fixtures, 5 right in neutral rotation and 5 left in supination. These limbs were subject- ed to a 134 N load by means of a servohydraulic press (Instron) and measurements were obtained at the proximal and distal radius with strain gauges and at the radiohumeral joint with a Tekscan pressure sensor. 10% of the distal ulna was then excised, the load reapplied and measurements obtained. This process was repeated in 10% increments until 50% of the distal ulna was excised. Results: A significant increase in strain was found at the proximal radius with a 10% and 20% excision of the distal ulna in supination (p=.041, p=.039 respectively) when compared to the intact specimen. However, a significant decrease in strain was found in the proximal radius with a 20% excision in the neutral position (p=.031). No significant differences were found at any other level of excision including after 50% of the ulna was excised. Analysis of the data obtained from the Tekscan revealed a significant increase in pressure at the radiohumeral joint with a 20% excision of the supinated specimen when compared to the con- trol (p=.044). No other significant differences were found by the Tekscan methodology. There was no significant difference found between neutral and supinat- ed positioning of the upper limb with respect to controls or at any level of excision of the distal ulna with either mode of evaluation.

Conclusions: Although good clinical results can be obtained with wide excision of the ulna, changes in radioulnar load transfer and radiohumeral joint pressures do occur and may have long-term clinical significance.

87 The Distal Radio Ulna Joint Prosthesis as an Effective Last Resort after Failed Salvage Procedure; A Atudy of Functional Outcomes in 18 Cases Institution where the work was prepared: cmki, Louisville, KY, USA Adam Goodwin; luis laurentin; Christine M. Kleinert Institute

Purpose: Salvage procedures for distal radio ulna joint arthritis include resection or replacement of the ulna head. These can result in painful impingement of the dis- tal ulna remnant against the radius during weight bearing or, following ulna head replacement, subluxation of the ulna. The Scheker distal radio ulna joint prosthesis comprising of an ulna stem and radial ultra high molecular weight polyurethane ball and socket, restores the functional relationship between the radius and ulna. The initial study group comprised 31 patients with failed distal radio ulnar joint ablation.

Methods: All 31 first generation DRUJ prosthesis patients were contacted after a minimum of 3 and a maximum of 9 years follow up post surgical treatment. 13 were lost to follow up or unavailable to participate. 18 completed the DASH, PRWE and pre and post operative pain score questionnaires. In all 18, range of motion, grip strength and weight bearing ability in a pronated and neutral position were compared between the treated and contralateral side.

Results: Mean PRWE scores were 30.14 following DRUJ prosthesis and mean DASH scores were23.1. Patients subjectively scored pre operative pain on a five point scale at a mean of 4.29 and post operative pain at 0.94. Mean pronation following DRUJ prosthesis was 89% of the contralateral side and supination, 86%. Grip strength as evaluated by Jamar II was 67% of the contralateral side. In the 15 wrists that had not also undergone previous fusion, extension was 88% and flexion was 71% of the contralateral side. One patient developed CRPS and was unable to bear any weight, but of the remaining 17 patients, 13 were able to lift ten pounds with the treated side, 11 without any pain in the neutral position. 8 were able to lift 20 lbs, 5 without any pain in the neutral position.

Conclusions: Ablation of the ulna head can result in significant morbidity. This study demonstrates in 18 patients with unacceptable functional deficit following Darrach, Sauvé-Kapandji, Bower and Watson procedures, the first series Scheker DRUJ prosthesis provides another option in the treatment of distal radio ulna joint dis- ease. Subjective and objective outcome measures were closely comparable to the contralateral untreated side and indices of patient satisfaction were high. The prosthesis restores the radio ulna functional relationship sacrificed by ablative procedures and as such represents a significant advancement in the treatment of challenging distal radio ulna joint disease.

The “Fovea” Sign for Defining Ulnar Wrist Pain: An Analysis of Sensitivity and Specificity Institution where the work was prepared: Mayo Clinic College of Medicine, Rochester, MN, USA Shian Chao Tay, MD1; Kazunari Tomita, MD1; Richard A. Berger, MD, PhD2; (1)Mayo Clinic College of Medicine, (2)Mayo Clinic

Purpose: Eliciting tenderness in the region of the ulnar head fovea is a possibly useful clinical test for defining the source of ulnar-sided wrist pain. Until now, no reports of the clinical sensitivity and specificity of this test have been available. Based upon anecdotal observations, a hypothesis was developed and subsequently test- ed which stated that ulnar fovea tenderness (positive "fovea sign") is sensitive and specific in detecting two ulnar sided wrist conditions: foveal dissociation of the distal radioulnar ligaments, and ulnotriquetral (UT) ligament injuries.

Methods: After IRB approval, the clinical and surgical records of all patients who presented to the hand clinic of the senior author from the time the "fovea sign" test was developed through the present who subsequently underwent wrist arthroscopy were reviewed (N=272). Data recorded included the presence or absence of the "fovea sign", relevant findings on concurrent clinical and imaging examinations, and the findings of pathology recorded at the time of surgery. All exam- inations and surgery were carried out by the senior author.

"Fovea Sign" The "fovea sign" test is executed by pressing the examiner's thumb distally into the interval between the ulnar styloid process and flexor carpi ulnaris tendon, between the volar surface of the ulnar head and the pisiform. A positive “fovea sign” is designated when there is exquisite tenderness that the patient claims replicates their pain, with comparisons made with the contralateral side.

Results: The median age was 33.7 years (range, 12.6 to 74.7 years), with 53.7% males. The right side was the symptomatic side in 53.4% (57.7 % dominant side). A history of trauma was present in 75.4%. Ulnar sided wrist pain was the site of predominant pain in 55.1% (150 patients). The "fovea sign" was positive in 156 patients. There were a total of 90 foveal dissociations and 88 UT ligament injuries diagnosed on wrist arthroscopy. The sensitivity of the “fovea sign” in detect- ing foveal dissociations and/or UT ligament injuries was 95.2%. Its specificity was 86.5%.

Conclusions: The hypothesis stating that the “fovea sign” is a useful clinical maneuver to detect foveal dissociation and UT ligament tears is supported. The conditions thus elicited represent two common sources of ulnar-sided wrist pain. The differentiation between the two conditions may be made clinically, where UT ligament tears are typically associated with a stable DRUJ and foveal dissociations are typically associated with an unstable DRUJ.

88 Failed Darrach Procedure: an Allograft Solution Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA Filippos S. Giannoulis1; Jeffrey A. Greenberg, MD2; Rob W. Weiser, PA-C1; Dean G. Sotereanos1; (1)Allegheny General Hospital, (2)Indiana Hand Center

Purpose: We describe a new technique for the treatment of painful instability of the distal ulna after Darrach procedure using an allograft as a mechanical interposi- tion. The purpose of the study is to evaluate the results of this technique.

Methods: In this study we report on 17 patients who underwent revision of their Darrach procedure using an allograft (human Achilles tendon allograft). The average age of the patients was 47 years (range 39-68) and the average time after the original procedure was 15 months. The indication for the revision surgery in all patients was incapacitating pain over the distal stump of the ulna which increased during pronation or supination and with active grip. Pain was assessed using a VAS (Visual Analog Scale). Grip strength was measured using a dynamometer. All patients had instability of the distal ulna, and crepitus or palpable “click- ing” during forearm rotation. Radiographs of all patients demonstrated erosion of the medial cortex of the radius, indicating impingment. Technique: 2 or 3 suture anchors were placed into the medial cortex of the radius, proximal to the sigmoid notch where the impingment occurred. An adequate amount of the allograft was then sutured into an anchovy. The size of the allograft was determined by pronating and supinating the involved forearm with pressure applied to the ulnar aspect of the ulna to assess crepitus. Sutures were placed through the allograft, creating a pillow-shaped spacer. Two or three drill holes were then placed into the distal ulna for fixation of the allograft to the ulna. With final allograft placement there should be significant padding between the radius and the ulna to prevent any palpable crepitus during forearm rotation under compression.

Results: After an average follow-up time of 34 months all patients were re-evaluated by subjective assessment, range of motion, grip strength, pain relief and radi- ographs. We report 16 patients with good and excellent results and 1 patient with persistent complaints (our first patient). There were no radiographic changes noted.

Conclusions The use of an allograft as a mechanical interposition between the radius and the ulna has not been described previously.With this technique there is no need for a metallic prosthesis and as much bulk graft as necessary is obtainable. We believe that this technique is an excellent alternative to metal arthroplasty for reconstruction of difficult cases of failed distal ulna resection.

Biomechanical Evaluation of Volar Locking Plates for Distal Radius Fractures Institution where the work was prepared: Stony Brook University, Stony Brook, NY, USA Scott Michael Levin, MD1; Glenn Alan Teplitz, MD2; Cory Oliver Nelson1; Jonathon Devlin Botts1; Yong Kwon1; Frederick James Serra-Hsu1; (1)Stony Brook University, (2)Winthrop University Hospital

Introduction: The development of fixed-angle devices have been a major advancement in orthopedic fracture care. The strength of these fixed angle constructs combined with the benefits of using a volar approach for distal radius fractures, have made volar locking plates an attractive option for fixation of these fractures. This study compares the biomechanical strength of two popular existing volar locking plate systems (Synthes LCP and Hand Innovations DVR) along with a non- locking volar T-plate (Synthes).

Methods: Formalin-fixed cadaver forearms were used for this study. Each specimen was radiographed and any specimens with bony deformity were discarded. The spec- imens were divided into 3 groups (A, B, and C) with similar bone densities based on dexascans. A completely unstable extra-articular fracture pattern was cre- ating using a standardized technique. Group A was fixed with the Hand Innovations DVR plate, group B with the Synthes LCP plate, and group C with the Synthes non-locking T-plate. A materials testing machine was used to load each specimen in axial compression with 2000 cycles of 400 Newtons, represent- ing the physiologic loads created by flexion of all of the digits during the post-operative rehabilitation period as determined by previous studies. Stiffness, yield point, and ultimate strength were recorded for each construct.

Results: Each of the fixed-angle constructs completed 2000 cycles, whereas the non-locking plate failed at an average of 560 cycles. The mean stiffness of the Hand Innovations DVR plate, Synthes LCP plate, and the Synthes non-locking plate was 277.00 N/mm, 343.17 N/mm, and 175.67 N/mm, respectively. There was a statistically significant difference between both fixed-angle constructs and the non-locking plate (p<0.05), however, the difference between each fixed angle construct did not reach significance. Since, the non-locking plates failed the cyclical testing, yield point and ultimate strength could only be determined for the two fixed-angle devices. There was no statistically significant difference between the constructs for both yield point (Hand Innovations DVR=855.56 N, Synthes LCP=894.15 N) and ultimate strength (Hand Innovations=1021.97 N, Synthes LCP=1114.87 N).

Discussion: Based on the data from this study, fixed-angle constructs can withstand cyclical loading representing normal physiologic forces encountered during post-oper- ative rehabilitation. There was no significant difference observed between the two fixed-angle constructs for stiffness, yield point, and ultimate strength. Based on the results of this study, volar fixed-angle locking plates are an effective treatment for unstable extra-articular distal radius fractures, allowing early post- operative rehabilitation to safely be initiated.

89 Biomechanical Comparison of Different Volar Fracture Fixation Plates for Distal Radius Fractures Institution where the work was prepared: University of Colorado Health Sciences Center, Denver, CO, USA Kareem Sobky, MD; Kenneth Thomas, MD; Todd Baldini; Joel Bach; Jennifer Moriatis Wolf, MD; University of Colorado Health Sciences Center Purpose: To compare the biomechanical properties of four volar fixed- angle fracture fixation plate designs in a novel sawbones model, with test comparisons in cadaver bone. Methods: Four volar fixed angle plating systems were used on sawbone models that had a 10 mm section of the distal radius removed to simulate an unstable extra- articular fracture. Each construct, with six plates from each system, was tested to failure in axial compression. Six separate constructs with each plate type then underwent 10,000 cycles applying 100N of compression to simulate physiologic wrist motion and were then tested to failure in axial compression. Two plates from each system were also implanted in fresh frozen cadaver wrists with a section of distal radius removed in an identical fashion for testing. The cadaver wrists were tested in axial load to failure for comparison to the sawbones. The four plates used were the Hand Innovations DVR-A, Avanta SCS/V, Wright Medical Lo-Con VLS, and Synthes volar plate. Results: All groups were loaded to failure. All failed with an apex volar angulation. The Hand Innovations DVR-A plate demonstrated significantly more strength in load to failure and failure after fatigue cycling (p = .000007 for single load and p=.0019 for fatigue failure) in a sawbones model. In cadavers there was no signif- icant difference among the groups (p value = .85) in axial compression failure. The cadaveric model demonstrated an identical failure mode to sawbones, but forces were approximately a magnitude higher to cause failure of the bone. The Avanta SCS/V plates were the only noted to have any amount of pullout of the distal fixation, occurring in two of twelve plates. Conclusions: Volar fixation of unstable distal radius fractures with a fixed angle device is a reliable means of stabilization. The Hand Innovations DVR-A plate fixation sys- tem was the most rigid of the systems tested.

Why Plate? Fractures of the Distal Radius: A Unique Approach Institution where the work was prepared: M Ather Mirza MD PC, Smithtown, NY, USA M. Ather Mirza, MD; Mary Kate Reinhart, CNP; M. Ather Mirza, MD, PC Purpose: To assess the radiographic, clinical and functional outcome of patients with distal radius fractures treated with a minimally invasive, non-bridging external fixator. Methods: Over an 18 month period, patients with distal radius fractures (DRF's), extra-articular; displaced, non-displaced and intra-articular; non-displaced, reducible displaced fractures were treated with a minimally invasive cross pin fixation (CPX) system with an unobtrusive lightweight non-bridging external fixator /strut. A removable, custom splint applied 5-7 days post-operatively allowed early mobilization of the wrist. Radiographic measurements: radial height, radial inclina- tion, and palmar tilt were recorded post reduction, post removal of fixation and at 6 months post-op. Outcome instrument scores were obtained 5-10 days, 3, 6 and 12 months post-op using the DASH and Patient Rated Wrist / Hand Evaluation (PRW/HE).Wrist range of motion (ROM), grip and pinch strengths were measured at specific intervals by an Occupational /Certified Hand Therapist. Results: 26 consecutive patients were treated with the CPX external non-bridging system. 1 patient was excluded in the early postoperative period due to non-compliance. The remaining 25 patients, 19 females and 6 males, mean age 60 (range 28-87) presented as 11 right, 15 left /15 dominant, 10 non-dominants, 1 mixed domi- nance DRF's. Anatomic reduction was maintained. Wrist ROM was compared to the contralateral side, at 12 weeks: dorsiflexion 77%, volarflexion 66 %, prona- tion 94%, supination 83%, and at 1 year: DF 92.5%, VF 87%, pronation 96%, supination 102%, was achieved. At 6 months, mean grip strength was 84% of the contralateral side and 98% at 1 year. Instrument outcomes at 6 months and 1 year revealed mean scores respectively; DASH: 17.5 and 9.43, PRW/HE: 22 and 15. Conclusion: This study demonstrates that the CPX external non-bridging system is an effective minimally invasive surgical procedure for stabilization of DRF's. Radial height, palmar tilt and radial inclination are maintained. Good clinical and functional results were obtained as well as comparable DASH and PRW/HE outcome scores.

Dupuytren's Diathesis Revisited- Modification of an Important Prognostic Indicator Institution where the work was prepared: University of Manchester, Manchester, United Kingdom Sandip Hindocha, MBChB; John K. Stanley, MCh, Orth, FRCS; Stewart J. Watson, MRCP, FRCS; Ardeshir Bayat, MD, PhD; University of Manchester

Hueston originally coined the term "diathesis" relating to certain features of Dupuytren's disease (DD) dictating an aggressive course of disease. His initial description of DD diathesis include four factors; ethnicity, family history, bilateral DD and ectopic lesions. The degree of diathesis is considered highly signifi- cant in predicting recurrence (new DD lesions in the same area of surgery) and extension (new DD lesions outside the area of surgery) of DD following surgi- cal management. However, to date there are no clear data regarding the accurate predictive value of various features of DD diathesis. Prognostic indicators of risks associated with surgery are important. We aim to evaluate the current criteria and formulate a statistical predictive value for DD diathesis. Caucasian patients diagnosed with DD between the ages of 25-90 years (n=322) from Northwest of England were assessed for DD diathesis with a clinical his- tory and examination. DD diathesis assessment was analysed by calculating odds ratios of developing recurrent DD using logistic regression. Ethical approval and written consent by all patients were obtained. The observed recurrence rates in presence of significant risk factors and corresponding odds ratio (OR) of recurrent DD were calculated. Of note recurrent dis- ease was observed in; 46% males (OR=1.72, p=0.03); 47% with bilateral DD (OR=1.48, p=0.07); 48% with family history of DD (OR=1.32, p=0.14); 47% with age of onset less than 50 years (OR=1.47, p=0.09), 52% in those with ectopic lesions (OR=1.54, p=0.07); and in 63% with Garrod's pads (OR=2.5 p=0.006). The original DD diathesis factors; Caucasian ethnicity, family history, bilateral DD and ectopic lesions have been modified. Our modified DD diathesis includes; Caucasian ethnicity, family history with one or more affected sibling/parent, bilateral disease(nodules or contractures in palm or digit), ectopic lesions in the knuckles (Garrod's pads), male gender and age of onset less than 50 years. The presence of smoking and alcohol consumption is controversial and therefore not included in the modified DD diathesis. The presence of all new DD diathesis factors in a patient suggests a strong diathesis and increases the risk of recur- rent DD by 71% compared to a baseline risk of 23% in those with none of these modified DD diathesis factors.

90 Safety and Efficacy of Injectable Mixed Collagenase Subtypes in the Treatment of Dupuytren's Disease, Early Phase III Results Institution where the work was prepared: Auxilium Pharmaceuticals, Inc, Malvern, PA, USA Marie Badalamente, PhD; SUNY-Stony Brook; Lawrence Hurst, MD; SUNY at Stony Brook

Purpose: To assess the efficacy and safety of injectable collagenase subtypes in reducing the degree of contracture in metacarpophalangeal (MP) and/or proximal inter- phalangeal (PIP) joints in patients with Dupuytren's disease (DD).

Methods: In this randomized, double-blind, placebo-controlled study, patients with Dupuytren's disease were randomized in a 2:1 ratio to receive an injection of 0.58- mg mixed collagenase subtypes (AA4500, Auxilium) or placebo. Thirty-five adults, 28 males and 7 females, mean age 63 years with flexion deformity of ?20° of the MP and/or PIP joints were enrolled. Patients could receive a maximum of 3 injections in the primary joint, at 4-6 week intervals. Follow-up visits occurred 1 day, 1 and 2 weeks, and 1 month after each injection. The primary efficacy variable was overall clinical success (primary joint correction to 0°-5°of exten- sion) after the last injection. Subsequent joints could be injected. Flexion contracture, range of motion, grip strength, and adverse events were evaluated. Statistical comparisons between groups were conducted using 2-sided t-tests with P?0.05 significance.

Results: Of the 35 patients, 21 patients had MP and 14 patients had PIP contractures as the primary joint. Twelve patients (7 MP, 5 PIP) received placebo, and 23 patients (14 MP, 9 PIP) received mixed collagenase subtypes. Clinical success was achieved in 21 of 23 (91%) patients treated with mixed collagenase subtypes in the primary joint, whereas, zero of 12 placebo-treated patients attained clinical success in the primary joint (P<0.001). There was no loss of grip strength or normal range of finger motion in any patient. The mean number of injections required for clinical success in the primary joint was 1.4±0.74 (n=23) (1.3±0.62 in MP (n=14) and 1.6±0.88 in PIP (n=9). In mixed collagenase-treated joints, the mean time to success was 8 days. All patients treated with mixed collage- nase subtypes had an adverse event compared with 9 of 12 (75%) placebo patients. Injection site pain, peripheral edema, and ecchymosis were the most com- mon study drug related adverse events. All adverse events resolved well in 6-13 days. No serious drug related adverse events were observed. Longer-term fol- low up was 1.6 years.

Conclusions: Injection with mixed collagenase subtypes (AA4500) successfully corrected MP and PIP joint contractures in 91% of patients with DD compared with 0% of placebo-treated patients. The most common treatment-related adverse events were injection site reactions which resolved well.

91 AAHS Concurrent Scientific Paper Session 1B

The Effect of IL-10 Overexpression on the Biomechanical and Histological Properties of Healing Tendon Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA Sudheer Reddy, MD1; Eric T. Ricchetti1; Miltiadis H. Zgonis1; Heather L. Ansorge1; Kenneth W. Liechty, MD2; Louis J. Soslowsky, PhD1; Pedro K. Beredjiklian, MD3; (1)University of Pennsylvania, (2)The Children's Hospital of Philadelphia, (3)Hospital of the University of Pennsylvania

Purpose: Interleukin-10 (IL-10) is a potent anti-inflammatory cytokine shown to inhibit scar formation in fetal wound healing. Overexpression has also been shown to create a permissive environment for adult scarless wound repair. However, the role of IL-10 in adult tendon healing and scar formation is unknown. The hypothesis of this study is that IL-10 overexpression will lead to reduced inflammation and scar formation in adult healing tendon and improved biomechanical and histological properties. Methods: Adult mouse patellar tendon was transfected (via injection) with an equine infectious anemia virus (EIAV) construct containing the IL-10 transgene (EIAV/IL-10) to create IL-10 overexpression. Successful transfection was confirmed by PCR, with IL-10 transgene expression peaking 2 days post-injection. Sixty-six, 10-week-old C57BL/6 male mice were utilized for the tendon injury study. Sham mice (n=32) received bilateral 10 microliter injections of sterile saline into their patellar tendon. Experimental mice (n=34) received bilateral 10 microliter injections of 1x10^10 viral copies/ml titer of EIAV/IL-10 vector. All mice then underwent bilateral, full-thickness, partial-width, central patellar tendon injuries 2 days post-injection. Mice were sacrificed at 5, 10, 21, and 42 days post-injury. Presence of IL-10 was analyzed via immunohistochemistry (n=4/group). Tendon healing was analyzed on histology (n=4/group) by assessing for degree of cel- lularity and collagen fiber organization at the injury site. Specimens also underwent biomechanical analysis (n=9-10/group). Results: Immunostaining revealed increased amounts of IL-10 at day 10 in the experimental group relative to sham. At day 21, however, the experimental group demonstrat- ed increased tendon cellularity on histology relative to sham. There was no difference in collagen fiber organization between groups at day 21 and 42. Maximum stress was significantly increased at day 42 in the experimental group (27.08±5.98MPa vs.19.59±6.33MPa, p< 0.01). Percent relaxation was significantly increased at both day 10 (66.38±12.07 vs. 56.67±7.45) and 42 (59.68±8.06 vs. 50.38±9.45) in the experimental group (p<0.05). Experimental tendons also demonstrated a trend towards greater modulus at day 42 (315.88±172.18MPa vs. 206.39±107.96MPa, p<0.06). No significant differences were observed 21 days post-injury. Conclusions: Superior biomechanical properties observed in experimental tendons at day 42 support the hypothesis that IL-10 overexpression can reduce scar formation and create a stronger tendon. Increased cellularity in the experimental group may be due to compensatory inflammatory mechanisms triggered by overexpression of IL-10. However, this model demonstrates that adult tendon can be successfully transfected with a viral transgene and that IL-10 overexpression can improve post-injury adult tendon healing.

Flexor Tendon Repair Using a Novel Polylactide/Polyglycolide Platform: Biomechanical & Immunohistochemical Analyses Institution where the work was prepared: Stanford University, Palo Alto, CA, USA Timothy R. McAdams, MD; Vincent R. Hentz, MD; James Chang, MD; Stanford University Medical Center

Purpose: The purpose of this study is to evaluate the biomechanical and histological characteristics of a novel tendon fixation device using a polylactide/polyglycolide platform for flexor tendon repair. Methods: A new method of flexor tendon repair was devised using a polylactide/polyglycolide platform in which no suture strands cross the laceration site (Fig. 1). The glide resistance of control intact zone II human cadaver tendons was compared to tendon lacerations repaired with the polylactide/polyglycolide platform device (n=3). Ultimate strength of tendon repair under in-vitro (no healing) simulated active ROM rehabilitation at 0, 2, 4, 6, & 8 weeks with the device was com- pared to standard 4-strand repairs (n=40). Load to failure testing was performed in the in vivo caprine (goat) model at 2, 4, 6, and 8 weeks after flexor ten- don repair using the device (n=16). Additional tendon repairs underwent tissue analysis at 8 wks post-repair: device (n=5) and 4-strand repair (n=1) and 4 wks post-repair: device (n=2) and 4-strand repair (n=2). Immunohistochemical analyis was performed using antibodies against H&E, Mason's Trichrome, collagen I & III, and Factor VIII for 8 week time point and only H&E at the 4 week time point. Results: In human cadaver tendons, glide resistance increased an average 0.21 lbs after deployment & 0.25 lbs after 1000 cycles. Ultimate strength of tendons repaired with the device under in-vitro (no healing) simulated active ROM rehabilitation averaged 13.4 lbs at 0 wks, 11.7 lbs at 2 wks, 11.1 lbs at 4 wks, 9.4 lbs at 6 wks, and 4.2 lbs at 8 wks.(p<.05 for all time points) In caprine tendons, ultimate strength of repair using the device was 20.2 lbs at 2 wks, 35.2 lbs at 4 wks, 45.2 at 6 wks, and 82.6 lbs at 8 wks. All device repairs were intact at 8 wks post-repair with no gap formation. Collagen I & III deposition was present across the laceration sites. Positive Factor VIII staining was also present, indicating vascular ingrowth. Minimal inflammatory reaction around the device was observed. Conclusions: The polylactide/polyglycolide platform tendon repair device provides fixation that will permit early active motion, minimal glide resistance, and adequate heal- ing without excessive inflammatory reaction.

92 Evaluation of Looped Suture and New Suture Material for Tendon Repair Institution where the work was prepared: Loma Linda University, Loma Linda, CA, USA Lawrence G. Sullivan, MD; Chad Brockardt; Montri D. Wongworawat, MD; Qiang Dai, PhD; Barry Watkins, MD; Loma Linda University

Purpose Flexor tendon repair strength is proportional to the number of suture strands crossing the repair site. It has not been shown if each strand needs to result from a separate pass through the tendon. Our purpose was to assess (1) whether one throw of looped suture across a flexor tendon repair site equals 2 separate throws of suture, and (2) whether or not 2-stranded Fiberwire repair is equivalent to 4-stranded Supramid repair.

Methods Seventy two Porcine flexor tendons were harvested and divided into 8 groups (n = 9). Transverse lacerations were created and repaired using simple Tajima configuration, looped Tajima suture, double throw Tajima, and four-strand cruciate suture. Tendon repairs were fixed to clamps and distracted at a constant rate of 10 mm/min (Instron), and the repair site was filmed with a digital video camera. The force at 2 mm gap, force at failure, and the gap at failure were recorded. Statistical analysis was performed using ANOVA and Kruskal-Wallis Multiple-Comparison Test.

Results The Supramid Tajima x 2 performed better than the Supramid Tajima-looped with respect to force applied to reach 2 mm gap (35 vs. 14 N) and gap at fail- ure (4.1 vs. 8.8 mm), p < 0.05. The 2-stranded Fiberwire Tajima performed similarly to the 4-stranded cruciate Supramid repair with respect to force at 2 mm gap (17 vs. 22 N), force at failure (42 vs. 46 N), and gap at failure (6.9 vs. 5.6 mm). Twenty-seven of the 36 repairs using Supramid failed at the knot, where- as 18/36 repairs using Firberwire failed at the knot and the other 18 failed by pullout from the tendon. Overall, when measuring by the above parameters, Fiberwire Tajima x 2 performed the best.

Force at 2mm (N) Force at failure (N) Gap at failure (mm) Mode of failure (suture:tendon) Supramid Tajima 8 32 8 9:0 Tajima-looped 14 50 8.8 7:2 Tajima x 2 35* 50 4.1* 9:0 4-strand cruciate 22 46 5.6 2:7 Fiberwire Tajima 17 42 6.9 8:1 Tajima-looped 25 56* 7.6 2:7 Tajima x 2 43* 72* 4.6* 6:3 4-strand cruciate 36* 44 3.3* 2:7 * significantly superior values, p < 0.05.

Conclusions With respect to force at 2mm and gap at failure, looped suture cannot substitute for 2 separate throws of suture. Two stranded Fiberwire Tajima repair equaled 4 stranded cruciate repair with Supramid for all tested parameters. Overall, Fiberwire Tajima x 2 provided the best biomechanical characteristics.

Biomechanical Analysis of a New Ultrasound Welded Knotless Tendon Repair Institution where the work was prepared: University College Hospital, Galway, Ireland Colin L. Riordan, MB, BCh, MRCS; Jeff Chan; Jack L Kelly; Padraic J Regan; University College Hospital Galway

Introduction: Results of zone 2 flexor tendon repairs remain unsatisfactory despite numerous different repair techniques and suture materials. Complex suture knots are dif- ficult to master, are bulky, may lead to excessive foreign-body tissue reaction, knot impingement and, ultimately, may compromise the repair. In this study we investigate the tensile properties of a novel ultrasonically welded knotless suture repair. Materials and

Methods: The AxyaWeld? Suture Welding System uses ultrasonic energy in a small probe-like instrument to compress and weld the two limbs of the suture. Porcine flex- or tendons (n=20) were repaired using a core nylon suture welded using the AxyaWeld® Suture Welding System (n=10) or a conventional 4-0 Ethibond four strand core suture (n=10). Repairs were pulled to failure using a Zwick® tensile testing apparatus. Load-elongation data, type and location of failure were recorded for each sample.

Results: The ultimate loads were significantly higher in the welded group (p<0.05). The welded group had significantly less (p<0.05) elongation at failure than knots. Tendon repairs in the welded group were stronger than the knotted group (p<0.05) at biological failure.

Conclusion: These results suggest that welded tendon repairs may provide strong, consistent and highly reproducible repairs compared to conventional knotted repairs where slippage may compromise the outcome.

93 Management of the Central Extensor Tendon on the Surgical Approach for Exposure of the Proximal Interphalangeal Joint: A Biomechanical Study Institution where the work was prepared: University of New Mexico, Albuquerque, NM, USA Keikhosrow Firoozbakhsh; Deana Mercer; Alex Carvalho; Moheb S. Moneim; University of New Mexico

Purpose: Since 1966 silicone implant arthroplasty has been used to treat arthritis of the PIP joint as an alternative to fusion. The volar approach to expose this joint spares the extensor mechanism at the cost of an increased risk of neurovascular damage. In the dorsal approach the extensor mechanism must be carefully handled, reattached and then protected during rehabilitation. Several surgical techniques have been used to handle the extensor mechanism [1-4]. Swanson et al. recommended incision of the central tendon in the midline followed by release of the lateral insertion on the middle phalanx and then reattachment to the base of the middle phalanx. Our clinical experience led us to a new surgical technique of splitting and then repairing the extensor mechanism without the bone reattachment as recommended by Swanson. The purpose of this study was to biomechanically test and compare the strength and function of this proposed simple technique with that of Swanson. Methods: Four pairs of fresh-frozen cadaveric hands were used. The index, long, and ring finger were harvested for testing. Twelve digits (3 digits x 4 hands) were des- ignated as control and were used to measure the fixation strength of Swanson's procedure. The other 12 digits of the paired hands were designated as exper- imental and were used to measure the fixation strength of the proposed new technique. The control specimens were prepared as described by Swanson. In the experimental group we exposed the PIP joint by splitting the central slip and repairing the halves with nonabsorbable sutures without reattachment to the bone. Extensors were loaded to 25 N at the rate of 1mm/second using the Bionex-MTS system. Force/displacement curves were produced and the load per unit displacement following tendon excursion were determined and statistically analyzed using paired t-test. Results: The mean ± SD were, respectively, 4.74 ± 0.46 N/mm for the control group and 4.62 ± 0.30 for the experimental group. The results were not statistically different, p =0.45. Discussion: The simple repair of the central slip without the bone reattachment preserves the function of the extensor mechanism on the PIP joint. In our clinical cases we haven't noticed any increase in the incidence of extensor lag or boutoniere deformity as a result of that. This technique can be also applied for fracture fixation in the area. References: [1] J Hand Surg 10A:796-805,1985. [2] Surg 5(3):141-147,2001.[3] J Hand Surg 26B:3:235-237,2001.[4] Ann Chir Main 7:179-183, 1988.

Did We Find a New Method in Solving the Mallet Finger Deformity? Institution where the work was prepared: University of Medicine "Iuliu Hatieganu", Cluj-Napoca, Romania Alexandru Georgescu, Prof, MD, PhD; Irina Capota; Ileana Matei; Filip Ardelean; UMF Iuliu Hatieganu

Mallet finger deformity is one of the most frequent encountered pathological entities after extensor tendons injuries, which appears as result of the disruption of an extensor tendon continuity over the distal interphalangeal( DIP ) joint. Despite the fact that a lot of methods were used in managing this invalidant deformity, the treatment of mallet finger is still a very debated subject. We'll try to demonstrate the advantages of a new surgical method by using a dorsal deepidermized flap rein- serted transosseous. The procedure starts by maintaining the DIP joint 0 degrees of extension by using a Kirschner wire. Then we perform an intradermical incision that delimitates a flap on the distally 2/3 of the dorsal aspect of the second phalanx, the distal end of the flap coinciding to the DIP joint; the width of the flap is of 3-5 mm, depending to the degree of swelling and the skin elasticity. The flap is deepidermized and then, after the incision is deepened on its both sides and dis- tally, it is raised superficial to the tendon. At the level of extensor insertion on the distal phalanx a hole of 1-1,5 mm is done. A steel thread 5/0 is passed through the distal end of the dermoadipous flap and is then passed through the intraosseous hole and knotted palmary in a tie-over manner. The extensor tendon is sutured with some 3-4/0 resorbable threads to the flap. The skin is closed over the flap. Postoperatively we immobilize only the DIP joint. The steel thread is took out after three weeks, the Kirschner wire after four weeks and the immobilization after five weeks. After that, the DIP joint is gradually weaned from the immobilization. We used this method in 97 cases. We have a recidive of the disease in10 cases, from which 3 cases required arthrodesis. The patients regain 95-100% of DIP stability and mobility, with an extension deficit of 0 to 10 degrees. In conclusion, this simple and effective method avoids a prolonged and uncertain immobilization and has a significantly high percent of success. The method uses local resources and avoids the rejection phenomenom related to allograft materials. The distal transosseous reinsertion and centromedulary wiring are important technical adjuvants and improve the final results.

Results of Tenodermodesis for Severe Chronic Mallet Finger Deformity in Children Institution where the work was prepared: Children's Hospital, Boston, MA, USA Tarik Kardestuncer, MD1; Donald S. Bae, MD2; Peter M. Waters, MD2; (1)Brigham and Women's Hospital, (2)Children's Hospital Boston

Introduction: Treatment of chronic soft tissue mallet fingers in children can be challenging, due to noncompliance with splinting, associated soft tissue injuries, and delays in diagnosis. The purpose of this investigation was to assess the results of tenodermodesis for the treatment of chronic or complex mallet fingers in children. Methods: A retrospective analysis of 14 children was performed. All had extensor lag greater than 45 degrees, absent distal interphalangeal joint (DIPJ) extension, and full passive DIPJ motion. Post-operatively, patients were evaluated for DIPJ motion, deformity, pain, functional limitations, and the need for additional treat- ment. Indications for surgery included chronic mallet fingers (n=7), tumor reconstruction (n=2), congenital abnormalities (n=2), or complex crush injuries to the fingertip (n=3). Average age at the time of surgery was 6.3 years (range 1.4 to 15.4 years). Results: At average 7.5 year follow-up (range 2 to 13 years), 12 patients (85%) had no pain or functional limitations of the affected finger. While 9 patients (64%) demonstrated mild residual extensor lag and 4 patients (28%) reported mild DIPJ flexion stiffness, all had intact active DIPJ extension and improved clinical appearance. Four patients (28%) had mild nail plate changes. No patients required additional surgical treatment. Conclusion: Tenodermodesis is a safe and effective technique for the treatment of severe chronic or complex mallet finger deformities in children. While active DIPJ extension and improved clinical appearance may be achieved, patients/families should be advised of the possibility of nail plate deformity and mild limitations in DIPJ motion.

94 Thumb Extension Is Immediate following Extensor Indicis Proprius to Extensor Pollicis Longus Tendon Transfer Using the "Wide Awake" Approach Institution where the work was prepared: Saint John Regional Hospital, Saint John, NB, Canada Michael Bezuhly, BSc, MD1; Gerald Sparkes1; Amanda Higgins2; Michael Neumeister3; Donald H. Lalonde1; (1)Dalhousie University, (2)Saint John Regional Hospital, (3)SIU School of Medicine Background: The elective use of low-dose epinephrine in hand surgery has allowed for the performance of simple operative procedures with tourniquet-free pure local anes- thesia (the “wide awake” approach). The absence of general anesthesia or sedation has, in turn, allowed for the observation of how quickly the sensorimotor cortex adapts following procedures such as tendon transfers. Methods: Seven patients underwent a “wide awake” transfer of extensor indicis proprius (EIP) to extensor pollicis longus (EPL) between February 2002 and May 2005 for restoration of thumb extension using local lidocaine with epinephrine alone. One of the seven patients experienced a rupture of their initial transfer, neces- sitating a transfer of extensor carpi radialis longus to EPL using the “wide awake” approach. Results: All seven patients were able to extend their thumbs fully via EIP intra-operatively immediately following transfer suture placement. Restoration of function was not ablated by loss of proprioception or visual feedback. At a mean follow-up of 15 months, thumb extension was restored to within normal limits in the affected thumb, with a slight decrease in grip and tripod pinch strengths. Conclusions: The “wide awake” approach has allowed us to adjust tendon transfer tension with active movement prior to skin closure without the risks associated with gen- eral or regional anesthesia. In addition, it has allowed us to observe immediate cortical adaptation in the context of a simple tendon transfer. We hypothesize that the brain's ability to immediately use EIP for thumb extension stems from the activation of pre-existing synergistic cortical finger movement programs.

Single Incision Repair with Suture Anchors for Treatment of Distal Biceps Tendon Rupture: a 59 Cases Follow up Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA Filippos S. Giannoulis, MD; Rob W. Weiser; Dean G. Sotereanos; Allegheny General Hospital PURPOSE: We describe the results of 59 patients who underwent treatment for acute distal biceps tendon rupture using a single incision and suture anchors. The pur- pose of the study is to evaluate if this method is reliable and if it can reduse the risk of ectopic bone formation or synostosis. METHODS: 59 patients underwent surgical repair for acute rupture of the distal biceps tendon, using suture anchors and a single incision. All performed by 1 surgeon. We had 58 male and 1 female with a mean age of 48 years (range 30-59). Our operative technique consisted of an “S”-shaped anterior incision centered over the antecubital fossa. After identification and protection of the lateral antebrachial cutaneous nerve, we exposed and mobilized the ruptured biceps tendon. The distal portion of the tendon was debrided and the radial tuberosity gently decorticated. A 4 stranded suture was then inserted into the tuberosity. The tendon was advanced to bone and the sutures were tied using the modification of Kessler's technique, holding the elbow in 90o of flexion. The post-op protocol was a posterior splint for 10 days (in 90o of flexion and 20o of supination), a dynamic hinged-extension block brace in 45o for 3 weeks and progressive advance- ment to full extension in 3 more weeks. Strengthening exercises were permitted after 3 months. RESULTS: All acute tears were repaired anatomically. The follow-up period was 39 months (range 18m – 11years). Objective data consisted of ROM (range of motion) of the elbow, flexion and supination strength were measured by a BTE Work Stimulator. The ROM was normal in 49 patients, 10 patients lacked 10o of exten- sion. 51 patients returned to their pre-injury level of activity and within 6 months returned to work. All patients reported pain relief and good recovery of strength and were completely satisfied of the outcome. There were no implant failures, nerve palsies or heterotopic bone formation. CONCLUSIONS: Use of a single incision repair with bone suture anchors provides secure fixation of distal biceps tendon to the radius with minimal volar dissection wich is associated with a minimum risk of synostosis and posterior interosseous nerve injuries. This method is reliable for acute ruptures. Return to normal strength and range of motion can be expected if tendon repair is performed before 3 weeks. The advantages of this method are less dissection for re-attachment of the tendon, less nerve injuries and no ectopic bone formation or synostosis.

Immediate Motion After Distal Biceps Repair Using a Dynamic Elbow Flexion-Assist Splint: Therapy Progression and Outcomes Institution where the work was prepared: Samaritan Hand Therapy Specialists, Corvallis, OR, USA Julianne Howell, MS, PT, CHT1; James Gyovai, PT, CHT1; Luis Vela, DO2; (1)Samaritan Hand Therapy Specialists, (2)Private Practice This presentation will describe the use of immediate motion with a dynamic elbow flexion-assist splint and prospectively report treatment outcomes after dis- tal biceps repair (DBR). Our series consisted of ten men 49 years old (range 40-56 years) who had their distal biceps tendon repaired by the same surgeon at 5.7 weeks post rupture (range 2-16 weeks). Six repairs involved the dominant extremity, 7 of 10 were repaired by modified Boyd-Anderson 2-incision tech- nique and 3 by Achilles tendon allograft. The rehabilitation program was initiated one week (range 2-11 days) after repair and was divided into 3 phases; pro- tective motion (0-6 weeks); active-controlled motion (7-8 weeks); and progressive resistance (2-6 months). During the protective motion phase a dynamic elbow flexion-assist splint -hinged at the lateral elbow was fabricated. Full elbow flexion was allowed by way of the splint's dynamic component. The arc of active elbow extension was controlled by a positive stop hinge. Initially the stop was set at 75° flexion; weekly thereafter for a total of 6 weeks the stop was adjust- ed by 15° increments to increase the arc of active elbow extension. The forearm was positioned within the splint in full supination for 6 weeks. Forearm prona- tion/supination was supervised weekly by the therapist within the allowable arc of elbow extension/flexion. At 6 weeks transition was begun between the pro- tected and active-controlled motion phases; the dynamic flexion-assist component was removed to permit full controlled active elbow and active forearm motion within the hinged splint. At 7 weeks the splint was discontinued. Starting at 8 weeks the resistive phase included progressive resistive exercise for elbow flexion, supination, flexion/supination and general upper extremity conditioning. Each patient was seen for an average of 13 visits (range 10-17) over a 17 week period (range 12-22). There were no complications. Therapy outcomes to be presented include AROM/PROM, isokinetic/isometric testing, DASH, PREE, and patient satisfaction scores. Results of EMG analysis of biceps activity during dynamic elbow flexion-assisted splint controlled motion and PROM will also be demonstrated. Analysis of the outcomes in this series of patients supports our immediate use of dynamic splint-assisted motion from full elbow flexion to 75° extension after DBR. Our program is a departure from programs that include static splints that immobilize the elbow at 90° elbow flexion. We believe that frequently cited ROM and muscle performance limitations may be minimize if surgeons and therapists collaborate in their efforts to improve rehab techniques.

95 Giant Cell Tumor of the Tendon Sheath: Risk Factors for Recurrence Institution where the work was prepared: Mount Carmel Medical Center, Columbus, OH, USA John G. Mowbray, MD1; Raymond K. Wurapa, MD1; John M. Bednar, MD2; Brent A. Bickel1; Damon C. Adamany1; (1)Mount Carmel Medical Center, (2)Thomas Jefferson University

Purpose: Giant cell tumor of the tendon sheath (GCTTS) is a common, frequently recurring tumor generally treated by surgical excision. This study was designed to iden- tify risk factors to assist surgeons and patients in predicting recurrence. Methods: A retrospective analysis of the surgical database was performed to identify all patients with a diagnosis of GCTTS of the hand who underwent tumor excision by 1 author over a 5-year period. Eighteen patients were identified and followed for an average of 39 months to monitor for recurrence. Results: Five tumors recurred in total, yielding a 27.8% recurrence rate. When tumor recurrence was examined, the authors noted that all occurred in patients older than 50 years (5/11), for a 45.5% recurrence rate. No tumors (0/7) recurred in patients younger than 50. This difference was statistically significant with a chi-square value of p<.04. Three recurrent tumors were intra-articular and 2 were extra-articular. Intra-articular tumors recurred at a 42.9% rate (3/7), while extra-articular recurrence was only 18.2% (2/11). Conclusions: This study found a statistically significant relationship between patient age greater than 50 years and tumor recurrence. This series also suggests that intra- articular extension may be linked to recurrence of giant cell tumors of the tendon sheath, although further investigation will be necessary to establish a sta- tistically significant link. The authors believe that patient age and determination of adjacent intra-articular extension may help the surgeon more clearly delin- eate the postoperative prognosis for GCTTS recurrence.

Recurrent Giant Cell Tumors of the Hand; a Prospective Study Institution where the work was prepared: Henry Ford Health System, Detroit, MI, USA Craig Oser, DO; Aamir Siddiqui, MD; Joseph Musial, PhD; Peter Janevski, MD; Henry Ford Hospital

Background: Giant cell tumors of the tendon sheath, located in the hand, remain a treatment dilemma. One has to balance the extent of the dissection and extirpation with the risk of recurrence. There is no consensus however, regarding how best to rate the risk of or predict recurrence. Our goal was to identify patients at high risk of recurrence based on the topography of the tumor and progression of the excision.

Methods: A prospective clinical case study of all biopsy-confirmed cases of giant cell tumor of the tendon sheath from a single institution was undertaken between 1997 and 2004. Cases were recorded in an anatomically-based operative registry which identified the surgical planes entered or tissues excised during the procedure. Complications and delayed recovery were also tracked.

Results: A total of 213 patients were included in this study. Mean follow up was 4.5 years. Overall recurrence rate was 13%. Chi-square analysis was performed in order to determine if there was an association between tumor recurrence and involvement of specific tissue structures as identified from the operative registry. According to the data analysis, there was an association between tumor recurrence and extensor tendon incision/excision, joint capsule incision/excision and location in the distal phalanx (p < 0.05). For the above sub-groups the recurrence rates were 23%, 30%, and 22%, respectively. There was no association for neurovascular, tendon sheath, flexor tendon or osseous involvement of the tumor at initial excision.

Conclusion: An anatomically-based registry was used to identify the high risk regions for tumor recurrence. This registry is derived from extremity sarcoma compartment excision principles. Within this paradigm, if a structure is directly involved with a tumor, extra care should be undertaken to confirm that there is no further involvement within or deep to that structure. Most authors agree that giant cell tumor recurrences represent incomplete initial excision. Our results suggest that the most likely risk factors associated with incomplete removal of the tumor include intricate involvement with the extensor tendon and or joint capsule. Location on the distal phalanx also correlates with increased recurrence. This intraoperative assessment designed to stage risk of recurrence offers a new approach to managing the complex problem of tendon sheath giant cell tumors of the hand.

Syndactyly Correction in Patients with Associated Syndromes Institution where the work was prepared: The Johns Hopkins School of Medicine, Baltimore, MD, USA William Dahl, BA; Johns Hopkins University School of Medicine; E. Gene Deune, MD; Johns Hopkins School of Medicine

Syndactyly is the most common birth defect affecting the limbs and is often associated with syndromes such as Poland's, Apert's, Holt-Oram, and some 25 others. Surgical correction of syndactyly is vitally important to preserve the function of affected digits. Most research into the correction of syndactyly has focused on correction of this condition in cases of non-syndromic syndactlyly alone. We have examined our experience in the correction of syndactyly in 47 patients with 152 releases, 12 of whom were affected by a syndrome listed above. A comparison of our outcomes revealed a significant difference in the need for reoperation between syndromic and non-syndromic patients. 58% of our syndromic patients as opposed to only 17% of our non-syndromic patients required reoperation to obtain optimal correction of their syndactyly. We also found that more complex syndactyly required reoperation at higher rates than simple syndactyly. 67% of syndromic patients with complex syndactyly as opposed to 50% of syndromic patients with simple syndactyly required reoperation to achieve optimal results. It is clear from this sample of patients that syndromic patients and their caregivers must be given realistic expectations about the need for reoperation to gain the best result functionally and cosmetically.

96 AAHS Concurrent Scientific Paper Session 2A

The Cause of Carpal Tunnel Syndrome? Institution where the work was prepared: University of Louisville, School of and Informatio, Louisville, KY, USA Steven J. McCabe, MD, MSc1; Vasyl Pihur1; Roberto S. Rosales, MD, PhD2; Isam Atroshi, MD, PhD3; (1)University of Louisville, (2)Unit for Hand and Microsurgery, (3)Kristianstad Hospital

Introduction: Carpal Tunnel Syndrome (CTS) is thought to be due to compression of the median nerve in the carpal tunnel. It is known that carpal tunnel pressures are ele- vated in wrist postures of flexion and extension and in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling and numb- ness. These classic symptoms stimulated our interest in the relationship of sleep to the development of CTS.

Method: We reviewed the literature surrounding the epidemiology of CTS and the literature regarding sleep disturbances such as insomnia, snoring, sleep apnea, and sleep paralysis. Through careful distillation of these studies and a process of reasoning, we have developed a hypothesis for the cause of CTS.

Results: Epidemiologically it has been shown that CTS is associated with age, gender, increased Body Mass Index (BMI), pregnancy, and is more common in some pop- ulations of Americans compared to Japanese. In this report we first present a summary of the literature showing these associations. We then distill the litera- ture surrounding sleep disturbances with a special interest in sleep position. Interestingly, the same associations noted above for CTS are strongly associated with sleep disturbances. For example, insomnia is associated with age and gender in a fashion that mimics the association with CTS. Similarly, like CTS, sleep apnea is associated with age and BMI. By compiling information from a variety of sources on the influences of sleep disturbances on sleep position we come to the startling but simple conclusion that the cause of CTS is sleeping on the side ie. in a lateral position.

Discussion: We believe that age, gender, BMI, pregnancy, and certain populations have an association with CTS because they all act through a common causative mech- anism, they cause increased sleeping in a position on the side. We believe this position puts the wrist at increased risk of flexion or extension, compressing the median nerve in the carpal tunnel. This realization has real clinical significance in that it focuses our attention on the early disorder when it is completely reversible. Our hypothesis has several strengths. This hypothesis is simple and bundles together a previously unconnected group of epidemiologic associations. It clarifies previously confused clinical circumstances such as the patient with classic symptoms and negative electrical studies. It creates research questions that can be tested and it invites us to change our clinical perspective in this most common form of nerve compression.

Comparison of Psychosocial Profile of Patients with Neuropathic Conditions Treated with and without Surgery Institution where the work was prepared: Hand and Microsurgery Center of El Paso, El Paso, TX, USA Jose Monsivais, MD; Hand & Microsurgery Center; Kris Robinson, PhD, FNP; University of Texas at El Paso

Purpose: The purpose of this study is to evaluate the functional results after surgical and non-surgical treatment of entrapment neuropathies and nerve injuries in chron- ic pain patients, some who had failed surgical treatment elsewhere.

Methodology/Design: We conducted an archival review of records from 91 patients treated for neuropathic pain over a ten-year period in a specialty clinic. Inclusion criteria includ- ed individuals with proven nerve dysfunction experiencing pain > 3 months. Diagnosis was established by history, physical examination, electrodiagnostic stud- ies and imaging. Multiple methods were used to determine sensory and motor function. Surgical candidates were determined by severity of sensory-motor abnormalities and had no evidence of untreated or uncontrolled depression or other psychological distress. Pain was not used as the sole indicator for any form of treatment. Surgical procedures included nerve decompressions, reconstruction, neurolysis, and excision of neuromas. Medical treatment included analgesics, adjuvants, and neuroleptic medications. Both groups received periodic clinical evaluation of sensory and motor function, and assessment of pain. Psychological reports included psychological diagnosis, results of Oswestry Pain Questionnaire, GAF, and PSS. Statistician conducted analysis which consisted of correlations and Chi Square using SAS statistical program. Sample size was set by power analysis. Using a correlational approach, a sample size of 85 is required to detect a medium effect size with alpha set at .05 and power of .80.

Results: The vast majority of patients returned to work and reported lower levels of pain up to 5 years after onset of nerve injury/ condition. Return to work was deter- mined by sensory and motor recovery. In addition, no differences were noted between groups on a variety of psychosocial measures after treatment including pain level (p=.2), litigation status (p>0.5), and return to work (p>0.05). The majority of individuals expected total relief of pain with surgical treatment. Reported drug and alcohol abuse was lower than that of the general population and did not differ between groups.

Conclusions: With psychosocial assessment, support, and adequate pain treatment, there seems to be no difference in functional outcomes on several levels between those patients receiving surgical and non-surgical treatment. Patients' expectations of surgery are unrealistic and must be addressed prior to treatment. Of interest, prevalence of past history of psychological dysfunction in this group is about twice that of the general population. This signifies that patients with chronic neuropathic pain are a group with special needs that if met may improve surgical outcomes.

97 A Detailed Cost and Efficiency Analysis of Performing Carpal Tunnel Surgery in the Main Operating Room Versus the Ambulatory Setting Institution where the work was prepared: Dalhousie University / Saint John Regional Hospital, Saint John, NB, Canada Martin R. LeBlanc, BSc, MD; Janice Lalonde, RN; Donald H. Lalonde, BSc, MSc, MD; Dalhousie University

Objectives: Our goal was to analyze the cost and efficiency associated with performing carpal tunnel release (CTR) in the main operating room versus the ambulatory set- ting. We sent out a survey to members of the Canadian Society of Plastic Surgeons to document the venue of carpal tunnel surgery practices in Canada.

Methods: A detailed analysis of the salaries of each involved person and the cost of materials involved in CTR performed in the main operating room versus the ambu- latory setting was done. A survey was emailed to practicing plastic surgeons in Canada to determine the venue of CTR performed by most of the surgeons.

Results: For a standard 3 hour surgical block, we are able to perform 9 CTR in the ambulatory setting vs. 4 operations in the main operating room. The calculated cost of performing CTR in the office setting is $296/case ($2664/9 cases), $333 ($3000/9 cases) in our clinic, and $401 ($3606/9 cases) in the main operating room. All of these costs assume use of local anesthesia with no sedation and no tourniquet (wide awake approach). Our survey demonstrated that 18% of respondents used the main operating room exclusively for CTR, while 63% used this setting for some of their CTR. The ambulatory setting was used exclusive- ly for CTR cases by 37% and 69% used this type of setting for greater than 95% of their cases. Most surgeons, 75%, did greater than 50 cases of CTR a year.

Conclusion: It would seem logical that CTR can be performed in an ambulatory setting at a reduced cost when compared to performing CTR in the main operating room. Our findings confirm this, and demonstrated a $105 per case maximum differential between CTR performed in an ambulatory setting versus the main operat- ing room. Even more importantly, we are only capable of performing 4 CTRs in the main operating room versus 9 CTRs in the ambulatory setting for a 3 hour standard surgical block. Therefore, less than half the numbers of patients are treated in the main operating room in the same time invested in the ambulato- ry setting. The use of the main operating room for CTR is more expensive, and less than half as efficient as CTR in an ambulatory setting. Our survey also demonstrated that many surgeons in Canada continue to use the more expensive, less efficient venue of the main operating room for CTR.

Pronator Syndrome: A Cadaveric Study of the True Sites of Compression Institution where the work was prepared: Southern Illinois University School of Medicine, Springfield, IL, USA Damon Cooney, MD, PhD; Reuben Bueno; Michael W Neumeister; Southern Illniois University School of Medicine

Pronator syndrome is a relatively rare compression neuropathy of the upper extremity. Controversy arises, however, as to the precise site of median nerve com- promise. The following study was a cadaver study defining the anatomic landmarks of compression of the median nerve in pronator syndrome. 20 fresh cadav- er limbs were dissected in a similar fashion carefully removing the fascial and muscle layers while recording their relationship with the median nerve in the arm and forearm. Reference points from the biceps tendon, the medial epicondyle and the lateral epicondyle were recorded. Similarly the relationship of the prona- tor, the FDS, and the FCR muscles to the median nerve were noted. The sites of impingement of the median nerve were recorded. A distinct fascial coalition existed between the FCR, FDS and the pronator muscles in the proximal forearm. Adequate decompression of the median nerve in the forearm requires and thorough understanding of the fascial and muscular inter-relationships to permit a definitive surgical release.

Outcome Study of Vascularized Ulnar Nerve Transposition in 100 Consecutive Patients with Cubital Tunnel Syndrome Institution where the work was prepared: Temple University Hospital, Philadelphia, PA, USA Julie Spears; Amit Mitra; Beth Mccampbell; Ravi Kiran; John Roussalis; Eva Chavez; Avir Mitra; Temple University

Ulnar nerve release at the elbow unlike procedures for other nerve entrapment syndromes has at best an unpredictable outcome. Various approaches are described for the release of ulnar nerve entrapment including inposition release,anterior transposition in subcutaneous, intramuscular or submuscular space. The proposed benefits of submuscular or intramuscular transfer include: less adhesion, better blood supply, and soft tissue protection. Despite all of the above claims, the out-come of ulnar nerve transposition has lacked satisfaction from patients and physicians alike. We postulate that the preservation of native blood supply during ulnar nerve transfer results in less scar formation due to its decreased dependence on the surrounding structures for nourishment. This is espe- cially important when the transfer involves a particularly significant length of the nerve. Preservation of the blood supply also prevents skeletonizing the nerve and thus scar formation, adhesion, and resultant clinical symptoms of chronic pain.

The present study evaluates the outcome of 100 patients who underwent vascularized ulnar nerve transfer in the sub-muscular position. This group of patients was compared with 25 patients who underwent traditional submuscular transfer. All patients were evaluated and treated at Temple University Hospital's sec- tion of Plastic and Reconstructive Surgery from 1985-2005. The vascularized transfer group's male to female ratio was 40:35. The age range was from twen- ty-three to seventy-eight years of age with an average of thirty-eight. Evaluation was performed by both a hand therapist and a physician prior to and after surgical decompression. The modified technique was performed through a standard skin incision, with standard preparation of the submuscular bed, release of the ulnar nerve, identification and preservation of the vascular supply of the ulnar nerve, mobilization of the ulnar nerve along with its blood supply and a rim of muscle.

Post-operatively, the patients were evaluated for relief of pain and paresthesias, return of two-point discrimination, grip strength, range of motion, degree of symptom relief, EMG results and return to work. Follow-up ranged from three months to 2 years. Evaluation of the data showed immediate improvement in pain, symptom relief of >80%, low incidence of scar tenderness, grip improvement, and an earlier return to work in the vascularized transfer group. The com- plication rate was <1% and the rate of recurrence was 0%. We propose that the modification of the standard anterior submuscular transposition technique produces superior results through the preservation of the blood supply and inclusion of a cuff of muscle.

98 Diagnosis for Hand-Arm Vibration Syndrome Institution where the work was prepared: Medical College of Wisconsin, Milwaukee, WI, USA Dennis Kao; ji-Geng Yan, MD; Hani S. Matloub; Lin-LIng Zhang; James R. Sanger; Yuhui Yan; Danny A. Riley; Michael Agrestic; David Rowe; Paula Galaviz; Judith Marechant-Hanson; Scott Lifchez; Medical College of Wisconsin

Introduction: There has been controversy about which tests should be performed to diagnose early Hand-Arm Vibration Syndrome (HAVS ).

Purpose: To find the most valid and reliable tests to diagnose HAVS. Material and

Methods: Group I: Control group of 12 volunteers without using vibrating tools. Group II: 12 workers using vibrating power tools for varying amounts of time. 1. Sensory nerve conductive tests. 2. Cold Stress-Temperature recovery time tests. 3. Blood test: S-ICAM, Sera Thrombomodulin, Norepinephrine. 4. Finger Sensory Evaluation: Semmes-Weinstein monofilament test and 2-point discrimination tests. 5. Digital blood pressure test.

Results: 1. Median nerve sensory conductive amplitude from palm to wrist :GI: mean 96± 31µm; GII: mean 43± 30µm; GI vs GII: P<0.001. Motor nerve conductive velocity (NCV): GI: mean 60.8± 8.5m/s; GII: mean 48.3± 5.9m/s; GI vs GII: P<0.001. 2. Cold-Stress Test: Temperature Recovery Rate(TRR) = T before test / T after 10 minutes. GI: mean: 85.36% ± 14.22. GII: More three years of using vibrating tools was a critical point, with vibration for 3 years, the TRR was 70%. Two subjects' TRR was 52% with 15 and 35 years of using vibrating tools. 3. Sera Chemical Test: A. sICAM: Standard Reference Range is 132.5-344.2ng/mL. GII: The value of 3 workers > 344.2ng/mL. Positive rate was 25.0%; B.Norepinephrine: Standard Reference Range is 0.8-3.4; 4 workers' value was <0.8 nmol/L. Positive rate was 33.3%. 4. Hand Sensory Evaluation: A.Semmes-Weinstein monofilament test: Standard criterion: Normal: 1.65-2.83; Diminished light touch: 3.22-3.61; Diminished protective sensation: 3.84-4.31; Loss of protective sensation: 4.59-6.65. 3 workers (3.5years) were normal; 9 workers (>5 years) were diminished. Positive rate was 66.98%. B. Two-point discrimination test: Normal is < 6mm. GI: 119/120 tested fingers were less than 6 mm; GII: 20/120 were < 6mm. Positive rate was 16.7 %. 5. Digital blood pressure test: Normal cut-off point: < 70 mmHg was abnormal. GI: none was < 70; GII: 8/23 fingers ; positive rate was 35%.

Conclusions: 1. Semmes-Weinstein monofilament test is a sensitive and simple test to assess HAVS. 2. Cold stress test gave a lower positive rate but did indicate later dam- age; however, it causes patient discomfort.3. Sensory nerve conductive and NCV were useful but need a control group value.4. The S-ICAM increased in 25%, and NE decreased in 33% of vibrated workers. 5. Digital BP test and 2-point discrimination test both have cut-off point value; they could be used to differ- entiate HAVS from simple carpal tunnel syndrome.

Neurochemical Response in Forelimb Tendons in a Rat Model of Upper Extremity WMSD Institution where the work was prepared: Temple University, Philadelphia, PA, USA Jane M. Fedorczyk, MS, PT, CHT1; Ann E. Barr, DPT, PhD2; Mamta Amin2; Marcus J. Handy2; Mary F. Barbe, PhD2; (1)Drexel University, (2)Temple University

Incidence of upper extremity tendinopathies increases with exposure to forceful repetitive motion. Increased presence of neurochemicals has been observed in patients with tennis elbow. Young adult female Sprague-Dawley rats were used to examine the neurochemical response to repetitive forceful work tasks in fore- limb flexor and elbow tendon tissues. Eighteen rats performed a high repetition high force task (HRHF; 60% maximum grip) in which grasping a lever occurred at a target rate of 4 reaches/min. Eight rats performed a low repetition low force task (LRLF; <15% maximum grip) at a target rate of 2 reaches/min. These tasks were performed 2 hrs/day, 3 dys/wk for up to 12 wks. Ten rats were controls. To examine for increased neurochemical production and their localization in distal flexor tendons, animals were euthanized with Nembutal, tissues collected, fixed in paraformaldehyde, and frozen-sectioned prior to immunohisto- chemistry using antibodies against NMDAr1 (BD PharMingen), SP (Chemicon) and CGRP (Chemicon). A microscope-linked bioquantification computer program was used to determine mean area fraction of neurochemical immunoreactivity (IR) in flexor endotenon, epitenon, and paratenon, bilaterally. Four-way ANOVA (group, week, limb, region) was used to determine differences. To examine for level of neurochemical production at the elbow, distal humerus and attached tendons/muscles were collected from 12 week HRHF and control rats, homogenized, flash frozen and stored at -80°C. Enzyme-linked immunosorbant assays (ELISA) were then performed for SP (MD Biosciences) and CGRP (Alpco Diagnostics). Two-way ANOVA (week and limb) was used to determine differences. SP- IR was significantly increased in flexor peritendon (epitendon+paratenon) at 3 and 12 weeks and endotenon at 3 weeks in HRHF rats. SP-IR was not increased in the LRLF flexor tendons, nor was NMDAr1-IR. However, NMDAr1-IR was significantly increased in flexor peritendon and endotenon at 6 weeks in HRHF rats. CGRP-IR was significantly different in flexor tendons regions, with peritendon > endotenon, but not between exposure groups. In elbow tissues, ELISA CGRP levels were decreased significantly in week 12 HRHF compared to controls, while SP was not significantly different. The inclusion of bone with the elbow tendon tissues may have diluted the neurochemicals to below detectable levels. Our findings demonstrate that SP and NMDAr1 immunoreactivity increases in distal flexor tendon as a consequence of performing highly repetitive and forceful tasks. The response is tissue (peritendon >endotenon) and duration depend- ent. Increases in neurochemicals may be linked to persistent pain associated with tendinopathies of the upper extremity. Grant support: CDC-NIOSH(MB), NIAMS(AB), and AAHS(JF).

99 Comparison of Return to Work: Endoscopic Cubital Tunnel Release versus Anterior Subcutaneous Transposition of the Ulnar Nerve Institution where the work was prepared: Orthopaedic Specialists, Davenport, IA, USA TYSON Cobb, MD; Patrick T Sterbank, PA-C; ORTHOPAEDIC SPECIALISTS, P.C Endoscopic Cubital Tunnel Release (ECTR) is an emerging technique with speculated advantage of a smaller incision and earlier return to activity. Several ear- lier studies have demonstrated clinical efficacy of ECTR but early return to activity has not been clearly documented. The purpose of the study was to com- pare the return to work time for patients undergoing ECTR versus Anterior Subcutaneous Transposition of the Ulnar Nerve (ASTUN). METHODS: A retrospective review of 30 consecutive cases was used to determine the time from surgery to return to work. Follow-up time averaged one year for both groups. All patients had electrical studies prior to surgery. All patients had positive Tinel's and Elbow Flexion test. Severity of symptoms was rated preopera- tively using Dellon's classification. Postoperative results were graded using Bishop 12 point rating system. The ECTR study group consisted of 15 patients, 6 females and 9 males, 11 workmen's compensation and 4 group insurance; average age was 49 years, range 28 to 69. Dominant side surgery occurred in 8 cases (54%). Average length of preoperative symptoms was 26 months. 10 (68%) patients had a positive elec- trical study for Cubital Tunnel. Preoperative symptoms based on Dellon's classification were 10% Mild, 60% Moderate and 30% Severe. The ASTUN group consisted of 5 males and 10 females, 12 involved workmen's compensation and 3 private insurance, average age was 44 years, range 23 to 57. Dominant side surgery occurred in 9 cases (60%). The average length of preoperative symptoms was 28 months. 9 (60%) patients had positive electrical studies for Cubital Tunnel. Preoperative symptoms based on Dellon's classification was 7% Mild, 63% Moderate and 30% Severe. RESULTS: The ECTR results were 10 (68%) Excellent, 3 (20%) Good, 1 (6%) Fair and 1(6%) Poor utilizing the Bishop12 point rating system. The average return to mod- ified work was 2 days (range 1 to 3) and to regular work 7 days (range 5 to 9). The ASTUN group average return to modified work was 17 days (range 12 to 22) and for full duty 70 days (range 60 to 80). Results based on the Bishop 12 point rating system was 10% Excellent, 62% Good, 22% Fair and 6% Poor. All patients returned to their usual preoperative activities. CONCLUSION Endoscopic Cubital tunnel release provides good to excellent symptom relief in most patients with an earlier return to activity compared to ASTUN. The dif- ferences in recurrence, complications, and long-term outcome require additional study.

Peripheral Nerve Injuries and Nerve grafting Institution where the work was prepared: Boston University School of Medicine, Boston, MA, USA Harilaos Theodore Sakellarides, MD; Boston University School of Medicine

This paper evaluates the results of bridging large nerve defects with thin autographs in a series of 130 patients. Previously applied methods of nerve grafting had disappointing results. Over a span of 10 years, new techniques have been used, namely microscope, microsurgical techniques, and fine suture material. Seventy involved the median nerve, 40 the ulnar nerve and 20 the radial nerve. Ages ranged from 20 to 60 years. The time from the injury to grafting was from 6 months to 5 years. Evaluation of nerve repairs was according to the British method. Experimental work proved: 1) The detrimental role of tension at the suture line. 2) The deleterious effect of postoperative stretching on successful functional recovery. 3)Regeneration axons advanced more easily through nerve grafts of 2cm with two tension free anastomoses compared with a single suture under tension. The epineurium was the primary source of connective tissue proliferation. Motor recovery: Median nerve: Excellent 40%; Good 40%; Fair 20%. Ulnar nerve: Excellent 38%; Good 40%; Fair 22%. Radial nerve: Excellent 42%; Good 38%; Fair 20%. Encouraging results were obtained providing certain details of this method are strictly followed.

Humeral Shaft Fractures and Radial Nerve Palsy: To Explore or Not to Explore…That is the Question? Institution where the work was prepared: Grandview Medical Center, Dayton, OH, USA Matthew Heckler, DO; HB Bamberger; Grandview Hospital

Purpose: Humeral shaft fracture with radial nerve palsy has been the subject of debate since this entity was originally described in 1963 by Holstein and Lewis. Review of the literature demonstrates support for almost any approach in treating these patients. Consequently, today's surgeon is left without definitive literary guid- ance for the treatment of this injury. In order to clarify how physicians are actually treating these patients, we present a survey of practice tendencies toward observation versus operative intervention for humeral shaft fractures with radial nerve palsy. Additionally, we integrate this survey with the current literature using an “evidence based medicine” (EBM) approach to propose an algorithm directing treatment of these patients.

Methods: We conducted an anonymous online physician survey of practice tendencies for the treatment of humeral shaft fracture with radial nerve palsy. We surveyed three groups, the American Society of Surgery of the Hand (ASSH), the Orthopedic Trauma Association (OTA), and a group of residents.

Results: 558 surgeons from these three organizations responded. All groups agreed, 67%, that plate and screws are the implant of choice for fixation of a closed neurovascu- larly intact midshaft humerus fracture in an adult. Similarly, 86% of respondents and all groups agreed that open humerus fractures with radial nerve palsy should be explored. 60% of surgeons and all organizations agreed that the closed “Holstein-Lewis” fracture is not a primary indication for exploration. There was significant dis- agreement for treatment of patients with a secondary palsy. Respondents from the ASSH, 71%, were more uniform in recommending exploration for these patients. Opposite, the OTA and residents had a large contingent of respondents who where neutral or favored observation of these injuries, 53% and 58.6% respectively.

Conclusions: Overall, there are no prospective randomized controlled trials to definitively direct treatment of patients with humerus fractures and radial nerve palsy. However, with an EBM approach using literature review, textbooks, and our survey of physician practice tendencies, trends can be outlined. Most humeral shaft fractures can be treated non-operatively, but if operative intervention is indicated and there is associated radial nerve palsy, exploration of the nerve is warranted. Closed fractures with radial nerve palsy have a high incidence of recovery and observation is justified. Evidence trends toward primary exploration of open humerus fractures with radial nerve palsy. Finally, exploration versus observation for a “secondary palsy” is controversial, and either can be supported by current prac- tice tendencies and the literature.

100 Iatrogenic Injury to the Deep Motor Branch of the Ulnar Nerve in Percutaneous Pinning of 5th Carpometacarpal Fracture Dislocations: A Cadaveric Study Institution where the work was prepared: Albert Einstein Medical Center, Philadelphia, PA, USA Minn Saing, MD; James Raphael; Albert Einstein Medical Center

Background: Fracture dislocations of the 4th and 5th carpometacarpal joints are well described in the literature. However, there is little commentary available with regards to ulnar nerve injury related to these fractures and their management. A handful of case reports exist describing various levels of neuropraxia of the ulnar deep motor branch and postulate several theories to include repetitive trauma, initial fracture displacement, compression from hematoma, traction injury and iatro- genic injury from percutaneous pinning. We will report 3 case reports of patients with documented loss of ulnar nerve motor function post closed reduction and percutaneous pinning of a 5th carpometacarpal fracture-dislocation.

Methods: 5 cadaver specimens were thawed and under mini c-arm fluoroscopic guidance, a 0.045 in kirshner wire was placed in standard fashion, percutaneously from the dorsal lateral border of the 5th metacarpal base, across the hamatometacarpal joint and into the body of the hamate. The Kirshner wire is directed towards and into the body of the hamate. A dissection was then carried out to evaluate the proximity of the deep motor branch to the k-wire should the volar cortex be violated with our Kirshner wire.

Results: Our results confirm the close proximity of the deep motor branch of the ulnar nerve to the base of the hook of the hamate. In all 5 cadaver hands, the deep motor branch was within 2mm of the base of the hook of the hamate. The penetrated K-wire through the volar cortex of the hamate was within ≤1mm of the deep motor branch in all 5 cadavers.

Conclusions: Our study confirms the extremely close proximity of the deep motor branch to the volar cortex of the base of the hook of the hamate and also demonstrates the potential for injury during percutaneous pinning of 5th carpometacarpal fracture-dislocations.

Clinical Relevance: Care should be taken not to penetrate the volar cortex when performing closed reduction and percutaneous pinning of 5th carpometacarpal fracture-disloca- tions to prevent iatrogenic injury to the deep motor branch of the ulnar nerve.

Outcomes in Upper Extremity Replantation: a National Study of 16,128 Replants Institution where the work was prepared: Yale University, New Haven, CT, USA Michael Chen, MD; Yale University

Background: For many complex surgical procedures, there is an inverse relationship between volume and complications. Previously, our group has shown that as reimburse- ments for reconstructive procedures have declined, teaching hospitals are doing not only more of the upper extremity replants, but also more of the complex, multiple digit or hand replants. The purpose of this study was to determine whether this increase in replantation volume has led to less complications and bet- ter outcomes

Methods: We searched a national database of patients (the 1993-2002 Nationwide Inpatient Sample (NIS)) for failed upper extremity replants, defined as those patients who had had a subsequent amputation after their replantation. We then compared failure rates at teaching versus non-teaching hospitals. Furthermore, we examined the effect multiple replantation had on failure rates.

Results: 3,219 upper extremity replants were coded in the NIS, representing 16,128 replants performed in the U.S. from 1993-2002. Multiple digit/hand replants were more often subsequently amputated than single digit/hand replants (8.7% vs 5.2%). Furthermore, these failures led to an increased length of stay (7.5 days vs 5.8days, p<0.001) and total charge ($37,166 vs $26,785, p<0.001). Interestingly, even though teaching hospitals were taking on more of these multiple digit/hand replants and more replants in general, the amputation rate at teaching hospitals did not increase, whether a single or multiple digit/hand replant was performed. On the other hand, as the number of multiple digit replants declined at non-teaching hospitals, the failure rate increased nearly nine-fold to over 18%.

Conclusion: With respect to upper extremity replants, increased volume at teaching hospitals has not led to increased failure rates. In contrast, decreased volume at non- teaching hospitals has led to increased amputation rates.

101 Traumatic Thumb Reconstruction by Index Pollicization Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Cesar J. Bravo, MD; Alexander Shin, MD; Allen T. Bishop, MD; Steven Moran; Mayo Clinic

PURPOSE: Indications for pollicization of the index finger have decreased for traumatic thumb amputations/crush injuries. When the index finger is injured or severed in conjunction with the thumb, index pollicization becomes a powerful technique. The purpose of this study was to report the twenty five year experience at our institution using index pollicization for traumatic amputations/crush injuries of the thumb. METHODS: Seven patients treated by pollicization of the index finger after traumatic injury to the thumb were reviewed retrospectively. All included patients were males and the age at surgery ranged from 20 to 71 years, with a mean age of 43 years. Amputation levels included the metacarpophalangeal joint in two patients, the first metacarpal in two patients, and the proximal phalanx in three patients. The period between injury and pollicization ranged from 5 months to 4 years. Postoperative evaluations included thumb range of motion, opposition and pinch function, grasp and pinch strength, sensation, a "pick-up" test, and appearance. RESULTS: The follow-up period ranged from 5 months to 11 years, with an average of 4 years, excluding two patients who died during the follow-up period. All seven patients had excellent postoperative function and satisfactory results upon follow up. CONCLUSIONS: Pollicization of the index finger serves as an excellent adjunct for treatment of traumatic thumb amputations/crush injuries. Consistent results can be obtained while maintaining opposition and protective sensation after this procedure. However, technical demands are great and initial injuries to the thumb and index finger determine the final outcomes. Type of study/Level of evidence: Therapeutic, Level IV Key Words: Index pollicization, Traumatic amputations, Crush injuries to the thumb

The Free Style Concept in Harvesting Transpozition Island Perforator Flaps in the Forearm Institution where the work was prepared: University of Medicine "Iuliu Hatieganu", Cluj-Napoca, Romania Alexandru Georgescu, Prof, MD, PhD; Irina Capota; Ileana Matei; Filip Ardelean; UMF Iuliu Hatieganu

Relatively new method in flap's surgery, perforator flaps tend to monopolize nowadays the surgeon's interest. The question is: could these flaps be used not only as free flaps, as were mainly used until now, but also as local or regional flaps? Fu-Chan Wei developed the concept of free-style perforator flaps, refer- ring to the flaps harvested after a preoperative Doppler detection of the perforators. But, the regional or local perforator flaps could also be harvested without such preoperative investigations, through a very attentive flap design, function to the defect needs, and microsurgical dissection. Because these flaps need a microsurgical dissection, but do not need microvascular sutures, they could be defined as “microsurgical non-microvascular flaps”. The study refers to 49 per- forator flaps harvested in the forearm and based on perforator vessels from the radial, cubital and posterior interosseous artery. In the absence of a preopera- tive Doppler examination, the flaps were designed intraoperatively in a free-style manner. In each case we thought to 2-3 possible flaps able to cover the defect and, for the beginning, we drew only an incision possible to be one of the future flap edges. Then, we proceed to undermine one of the wound edges, trying to find a perforator pedicle able to provide the blood supply of the flap; if there is any well represented perforator, we do the same procedure on the second wound edge. Generally, it is impossible to not find a patent perforator. Only after that the design of the flap is completed. The length of the flap must have 2 cm more than the distance from the perforator to the most distally edge of the defect. As results, we did not find a perforator in only two cases, for which we found another covering method. It was a complete survival of the flap in 38 cases, a partial marginal necrosis which healed spontaneously in 7 cases, a total epidermal necrosis that needed secondary grafting in 2 cases and a complete necrosis in 2 cases. The donor site was directly closed in 18 cases and skin grafted in the remaining cases. Mean hospitalization time was 8 days. The follow-up was between 6 to18 months. In conclusion, the perforator flaps could be designed and harvested even in the absence of a preoperative Doppler examination, by an attentive dissection and design function of the defect needs.

Cryopreservation of Composite Tissue Transplants Institution where the work was prepared: University of Kentucky, Lexington, KY, USA Brian Rinker, MD; XD Cui; DY Gao; BF Fink; HC Vasconez; University of Kentucky

Introduction: The first successful human hand transplant was performed in 1999, ushering in the era of composite tissue allotransplantation. Strategies are being developed to induce donor-specific tolerance to allotransplanted tissues, eliminating the need for long-term administration of immunosuppressive drugs with the asso- ciated high morbidity. This is expected to vastly broaden the indications for composite tissue allotransplantation, placing a great demand on the donor pool. Cryopreservation has the potential to increase the availability of donor parts for transplantation, and may even reduce antigenicity of parts. The present study investigates whether the component tissues of composite flaps remain viable following cryopreservation and presents the early experience with microvascular isotransplantation of cryopreserved composite tissue flaps. Methods: 41 epigastric flaps were harvested from Lewis rats. 20 of the flaps were perfused with DMSO/trehelose cryoprotectant agent (CPA), frozen by controlled cool- ing to -140°C, and stored in liquid nitrogen for two weeks. 10 fresh and 10 cryopreserved/thawed flaps were sectioned and examined by light microscopy with H/E and factor VIII endothelial staining. 10 fresh and 11 cryopreserved flaps were analyzed with the MTT tetrazolium salt assay and an epithelial viability index was calculated. For the in vivo analysis, 30 flaps were divided into 3 groups. 10 flaps were transplanted fresh to isogenetic recipient animals. 10 flaps were per- fused with CPA and transplanted. 10 flaps were cryopreserved for 2 weeks, thawed, and transplanted. Transplants were inspected daily for viability. Results: In all cryopreserved samples, H/E and Factor VIII staining showed an intact, uniform endothelium which was indistinguishable from fresh specimens. On MTT analysis, the epithelial viability index for the 11 cryopreserved samples was 10.90±2.09, compared to 12.15±1.32 for fresh flaps (p=0.123). All freshly trans- planted flaps (10/10) were viable at 60 days, as evidenced by normal color and hair growth. 9 of the 10 flaps in the perfused/transplanted group were viable at 60 days; one flap exhibited partial loss. Survival of the 10 flaps in the cryopreserved/transplanted group ranged from 5 days to 60 days. Conclusion: Results suggest that the skin and vascular endothelial cells of composite tissue flaps retain their viability following cryopreservation and thawing. The in-vivo studies demonstrate that long-term survival following cryopreservation and isotransplantation of composite tissues can be achieved and support a delayed indi- rect injury rather than direct injury from freezing or cryoprotectant agents, as the mechanism of transplant loss.

102 AAHS Concurrent Scientific Paper Session 2B

Effects of the Deep Anterior Oblique and Dorsoradial Ligaments on Trapeziometacarpal Joint Stability Institution where the work was prepared: The University of Chicago, Chicago, IL, USA Matthew Colman, BA; Daniel Paul Mass; Louis Draganich; University of Chicago

Purpose: Osteoarthritis of the trapeziometacarpal joint of the thumb affects as many as twenty five percent of post-menopausal women. This study investigated the rel- ative contribution of the dorsoradial ligament (DRL) and deep anterior oblique ligament (dAOL) in limiting movement of the thumb in order to determine the relative contribution to stability of the trapeziometacarpal joint. This knowledge improves our understanding of the pathomechanics of osteoarthritis at the base of the thumb and may inform reconstructive surgical strategy.

Methods: Seventeen intact cadaver hands were dissected to reveal the DRL and dAOL. Either the DRL or dAOL was randomly transected, physiologic muscle loads were applied to simulate lateral key pinch or thumb opposition, and a three-dimensional magnetic tracking system was used to record the position of the first metacarpal relative to the trapezium. The differences in the three-dimensional positions between the control and transected states were determined.

Results: In lateral pinch, transection of the DRL resulted in a mean increased three-dimensional translation of 1.3mm, while transection of the dAOL resulted in mean increased three-dimensional translation of 0.6mm. Significant two-dimensional findings after transecting the DRL or dAOL included an increased palmar trans- lation of 0.3mm and 0.2mm, an increased radial (1.0mm) and ulnar (0.3mm) translation, and an increased pronation of 4.1 degrees and 2.4 degrees, respec- tively.

Conclusion: In most degrees of freedom of metacarpal movement relative to the trapezium, the DRL is relatively more important than the dAOL in providing stability to the trapeziometacarpal joint.

LRTI Carpometacarpal Joint Arthroplasty With Flexor Carpi Radialis Sparing Allograft: A Review of 30 Cases Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, PA, USA Dean G. Sotereanos; Filippos S. Giannoulis; Rob W. Weiser; Allegheny General Hospital

PURPOSE: Trapezial excision with ligament reconstruction combined with tendon interposition has proven to be a highly effective technique for the treatment of OA of the CMC joint. We believe the same procedure is possible with use of modern orthobiologics.

METHODS: 25 patients underwent surgical treatment for CMC arthritis with a new technique using Graft Jacket (Wright Med.) instead of FCR. Graft Jacket is an acellular human collagen (dermis) allograft. It is rapidly revascularized, repopulated with host cells and has high tensile strength. Technique: The Graft Jacket was rehy- drated and cut to create a 15cm strip. It was then placed around or sutured to the FCR (the anchor) and passed into the intramedullary cavity of the metacarpal as in the standard LRTI procedure. The remaining Graft Jacket is sutured together as an anchovy to fill the former trapezium gap, so that both suspension and interposition occurred. The mean age of the patients was 56 years and the median follow-up period was 1 year. All patients had marked pain and radiograph- ic evidence of severe arthritis before surgery. Pain, grip and pinch (tip and key) strength, stability and range of motion were measured pre- and post-opera- tively. Pain was assessed on a VAS (Visual Analog Scale). The ability to perform ADLs (Activities of Daily Living) requiring use of the thumb and to return to work were analyzed as well. Following surgery all thumbs were immobilized in a static splint for 10 days and then were placed into a removable orthoplast splint for 4-6 weeks. Radiographic examination was performed in all patients at the 10th post-op day, and also at 2 and 6 months after surgery.

RESULTS: Significants improvements were seen with grip strength (average 25lb) and tip (average 3.5lb) and key (average 4.5lb) pinch strength as well as palmar and radial abduction (average 25o). Pain was significantly reduced with an average of 6.0 on the VAS. There were no foreign body reactions or other infections in our series.

CONCLUSIONS: This study showed that excellent results can be achieved in strength, pain reduction, range of motion and ADLs with this new technique in which Graft Jacket was utilized instead of FCR in ligament reconstruction and interposition arthroplasty of the CMC joint. Our results indicate less morbidity than with use of FCR (swelling, ecchymosis or weakness) with excellent final outcomes.

103 Arthroscopic Cuetis Interpositional Arthroplasty of The Basilar Joint of The Thumb Institution where the work was prepared: Kaiser Permanente, Bakersfield, CA, USA Albert R. Swafford, MD; Kaiser Permemente

Introduction: Arthritis of the base of the thumb is common. Surgery is frequently necessary. This study investigates a minimal invasive technique of arthroscopic interposti- ional arthroplasty for isolated arthritis of the CMC joint of the thumb.

Methods: 38 arthroplasties in 36 patients are reviewed. All patients had failed non-surgical treatment. The arthrosopic treatment begins with suspension of the CMC joint of the thumb. A 1.5 or 2.3 mm arthroscope is utilized. The trapezial surface is debrided , smothed and leveled. Minimal bone is resected. Stabiliztion is aided by Thermal capsular plication. A Wright joint jacket is placed on the trapezial surface and secured. The thumb is immobilzed for 6 weeks. ROM and strenghen- ing are begun and continue for several weeks.

Results: 36 of the 38 procedures were satisfactory as to relief of pain and improved funtion. Recovery is typically acheived in 12 to 16 weeks. Preoperative pain(VAS) averaged 8.50; postoperative pain averaged 1.85. Pich preoperatively 4.8 lbs; postoperative pinch averaged 9.5. Two patients required revisiion. There were no additonal operative complications noted. Followup ranges from 6 to 48 months, average followup is 29.81 months.

Dicussion: Arthroscopic cuetis interpositional arthroplasty provides relief for patients with isolated CMC arthitis of the thumb. The height of the thumb and joint capsule are preserved. Biopsy has confirmed repopulation of the joint jacket with fibroblasts. Reconsitution of a joint space has been verified. Operative time, averging 51 minutes, is significantly less than comparable open procedures. Post operative pain, expressed in morphine equivalents, is also considerably less than open procedures. Revison if needed, is not impeded.

Long Term Outcome of Thumb Trapeziometacarpal Arthrodesis: A Review of 178 Cases Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Marco Rizzo, MD; Steven L. Moran, MD; Alexander Y. Shin; Mayo Clinic

Introduction: Arthrodesis has been reported as a procedure that effectively eliminates pain and affords stability of the unstable or degenerative trapeziometacarpal joint. However, the loss of motion (especially flatting of the palm) and a wide disparity in complication rates have made this option less attractive to some surgeons. The purpose of this paper is to review the long term results of thumb trapeziometacarpal arthrodesis with respect to clinical outcomes, union and complica- tions.

Methods: A retrospective review of basal thumb arthrodeses performed at our institution between 1970 and 2003. There were 178 hands in 158 patients (110 female, 48 male). Pre-operative and post-operative clinical and radiographic data was reviewed. The average age was 51.2 years (range 15-77). The dominant hand was involved in 101 cases. Diagnoses included: osteoarthritis (114), post-traumatic arthritis (11), inflammatory arthritis (11), prior brachial plexus injury (9), and arthritis due to instability (8), crystalline arthropathy (5). Fixation utilized included k-wires (139 thumbs), staples (14), tension band (13), plate and screw (5), compression screws (6) and none (1). Local or no bone graft was used in 61 cases and formal bone graft was utilized in 117 thumbs. Pre-operative pinch and grip strengths were 3.2 kg and 16 kg respectively. The average pain score was 6.2. Patients were contacted and/or seen to report overall satisfaction via a ques- tionnaire. The average follow-up was 12.2 years (range 2.5 – 30).

Results: There were 27(15.8%) nonunions. The diagnoses of these patients included: osteoarthritis (17), inflammatory arthritis (6), post-traumatic arthritis (2), and insta- bility (2). No correlation between the use of bone graft or type of fixation and nonunion rate was noted. There was a correlation between inflammatory arthri- tis and nonunion/pseudoarthrosis. Only 12 of 27 thumbs underwent re-operation or refusion. The pinch and grip strengths improved to 5.9 and 22 kg respec- tively. The average pain score improved to 0.7. Radiographic progression of scaphotrapezialtrapezoid (STT) arthritis was noted in 47 cases, and metcarpaopha- langeal (MP) arthritis was found in 22. However, symptomatic STT arthritis occurred in only 12 cases; one thumb went on to STT arthrodesis, another had takedown of CMC arthrodesis and LRTI, while 6 had steroid injections, and the remaining 4 were not severe enough to warrant intervention. No cases of MP arthritis required intervention.

Conclusion: Overall patient satisfaction was excellent and both grip and pinch strengths were significantly improved. Union rate was approximately 84%. Despite progres- sion of MP and STT arthritis, intervention was rarely warranted.

104 A New Frontier: Total Joint Arthroplasty for the Treatment of PIP Joint Arthrosis Institution where the work was prepared: The Permanente Medical Group, Sacramento, CA, USA Robert R. Slater, MD, FACS; The Permanente Medical Group

Introduction: Proximal interphalangeal (PIP) joint arthrosis is a challenging problem for patient and surgeon alike. Previously, the gold standard for its treatment was arthrode- sis, and many methods of performing that procedure have been described. More recently, new implants have been developed that offer an alternative treat- ment. Total joint arthroplasty of the PIP joint is now a viable option and is the subject of this report.

Methods: The Ascension total joint arthroplasty system was used in a series of patients to treat primary osteoarthrosis (OA) of the PIP joint. Indications were painful OA in fingers with adequate bone stock, adequate surrounding soft tissue quality and good muscle-tendon function. Patients were treated post-operatively accord- ing to protocols developed for this purpose. Follow-up visits included physical and radiographic exams and queries about patient satisfaction.

Results: To date, the prosthesis has been used in 9 joints (7 patients). All patients were female with an age range of 62-81 years. Concomitant procedures were done in some instances as indicated. Minimum follow-up was one year in all cases (maximum follow-up to date = 3 years). All patients were very satisfied with the level of pain relief and improvement of hand function, and they all said they would choose the procedure again and recommend it to others. With one excep- tion, all joints achieved between 82 and 90 degrees flexion with extensor lags of 0 to 10 degrees. That was a significant improvement vs. pre-op condition. Pinch and grip strength improved 30% vs. pre-op values, presumably primarily from pain relief.

Discussion: The Ascension PIP total joint arthroplasty system is made from a graphite core coated with pyrolytic carbon via chemical vapor deposition, resulting in a bio- logically inert polymer. It has a proven track record in long-term use in other arenas, such as cardiac valve prostheses. Pyrocarbon has an elastic modulus bet- ter matched to bone compared with alternative joint replacement materials. Use of the device for treating PIP joint arthrosis requires IRB approval; the FDA classifies it as approved for use under the restrictions of the humanitarian device exemption (HDE) policies. Early results as reported here are encouraging and are similar to results reported previously by the designing surgeons. The results warrant further study of the use of the device in those patients who meet the relatively narrow indications.

The Dorsal/Volar Method Improves Reliability in Measuring Wrist Range of Motion: An In Vitro Study of Reliability and Accuracy of Manual Goniometry Institution where the work was prepared: Hospital for Special Surgery, New York, NY, USA Aviva L. Wolff, BS, OTR, CHT; Timothy I. Carter, BA; Brian Pansy, BS; Howard J. Hillstrom, PhD; Sherri I. Backus-Saccoliti, DPT; Mark W. Lenhoff, BS; Scott W. Wolfe, MD; Hospital for Special Surgery

Background Despite its ubiquitous use in measuring objective outcomes of hand surgery and therapy, there is limited data concerning accuracy or repeatability of manual goniometry for wrist motion. The purpose of this study is to establish the accuracy and reliability (inter/intra-rater) of three manual goniometric alignment techniques°Xulnar, radial and dorsal/volar - in cadaveric upper extremities.

Methods External fixators were applied to ten cadaveric wrists with intramedullary canulated rods in the radius and third metacarpal for "gold-standard" fluoroscopic verification of posture. Wrists were positioned at angles of maximum flexion, extension, radial and ulnar deviation for reliability testing and at pre-selected angles across the range of motion for accuracy testing. At each position, wrist position was measured with a one-degree increment goniometer, and fluoro- scopic angles measured digitally. Manual goniometric measurements were captured by two raters, (hand surgeon/hand therapist) for reliability measurements, and by a single rater for accuracy. ICC and root mean squared (RMS) values were calculated for all combinations and ANOVA used to test differences between techniques (alpha <0.05).

Results No technique was statistically less accurate than another (6.73„a-7.52„a). Each method was found to have high intra-rater reliability, with each rater excelling in their preferred method. The dorsal/volar technique demonstrated the greatest inter-rater reliability (0.915) as compared to ulnar(0.501) and radial(0.384) respectively.

Conclusion Though each measurement technique demonstrated a similar degree of accuracy and intra-rater reliability, the dorsal/volar technique demonstrates the great- est level of inter-rater reliability. This parameter is important clinically, as measurements are regularly exchanged between hand surgeons and therapists.

105 Nerve Ending Distribution in Human Radiocarpal Ligaments: a Fluorescent Immunohistochemical Study Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Kazunari Tomita, MD1; Richard A. Berger, MD, PhD2; Evelyn Berger3; Kai-Nan An, PhD4; Jirachart Kraisarin, MD2; (1)Mayo Clinic College of Medicine, (2)Mayo Clinic, (3)Mayo Clinic/Mayo Foundation, (4)Orthopedic Biomechanics Laboratory Purpose: The function of nerve endings in human joints, including the wrist, is a topic of growing interest. Its implication in joint mechanics, dynamics and pathology is potentially great and probably underestimated to date. The purpose of this study is to report the distribution of nerve endings in radiocarpal ligaments as a fundamental step in improving our understanding of the neural influence on joint mechanics. Methods: Ligaments studied to date include 20 dorsal radiocarpal (DRC), long radiolunate(LRL) and short radiolunate(SRL) ligaments and 18 radioscapholunate (RSC) lig- aments. Each was harvested from ten paired fresh cadavers (5 males, 5 females, median age 74.5 yrs). The ligaments were fixed, cryostat sectioned at 50µm, serially collected and processed for fluorescence immunohistochemistry using PGP9.5 and a secondary antibody conjugated to a fluorescent tag(Alexa Fluor 488). The sections were evaluated with confocal laser microscope(2). Results: The total number and range of nerve endings in each ligament is shown in Figure1. Overall, more nerve endings were found in the DRC ligament than the pal- mar radiocarpal ligaments. There were no significant differences related to gender, age or side studied. There is a statistically significant difference in the num- ber of nerve endings in the DRC ligament and all three palmar radiocarpal ligaments(p<0.001). The distribution of nerve endings in each ligament is mapped. More nerve endings were found near the bony attachments and in the superficial half of the ligament. The concentration of nerve ending populations was greater in the epiligamentous sheath than the perifascisular space regions in the DRC and RSC ligaments(1). Conclusion: There are consistent patterns in the distribution of nerve endings in the radiocarpal ligaments. This suggests a functional significance which remains indeter- minate at this time. Future study will be required to define the role of neural integration in the wrist and its role in normal and pathologic mechanics.

Preliminary Results after Reconstruction of the Destroyed DRUJ with an Ulnar Head Endoprosthesis Institution where the work was prepared: Dep. of Hand, Plastic & Reconstructive Surgery -BG Trauma Center, Ludwigshafen, Germany Michael Sauerbier, MD, PhD1; Miriam Müller, MD2; Günter Germann, MD, PhD1; (1)Plastic & Hand Surgery of the University of Heidelberg, (2)Plastic & hand Surgery of the University of Heidelberg

Resection of the distal ulna, partial resection of the joint surfaces with or without interpostion of connective soft tissue, or fusion of the distal radius and ulna with creation of a proximal pseudarthrosis such as the Kapandji-Sauvé procedure are common methods to treat the arthritic destroyed Distal Radioulnar Joint (DRUJ). One of the drawbacks of these salvage procedures is the potential risk of painful radioulnar instability. Recent biomechanical studies showed the implan- tation of an ulnar head prosthesis as a promising procedure to restore the anatomy of the DRUJ. The purpose of this study was to evaluate preliminary results after reconstruction of the destroyed DRUJ with an ulnar head prosthesis. 15 patients with ulnar head prostheses were included in the study and examined clinically. Bilateral measurement of grip strength (JAMAR), active range of motion and subjective outcome data (DASH questionnaire) were analyzed. Primary ulnar head prosthesis implantation was done in 10 cases, implantation followed other surgical treatments (e.g. Darrach or Bowers procedure) in 5 cases. The average patient age was 49 years, 11 patients were male, 3 female, the average follow-up time was 14 months. The Average grip strength was 75 % of the contralateral hand, pro- /supination was 141 degrees (= 78 % of the contralateral hand), the average DASH score was 15 points. 13 patients of 14 were satisfied with the final result, in 2 patients the ulnar head prosthesis had to be removed due to an infection in one case and a persistent painful incongruence of the DRUJ in the second case.

Reconstruction of the TFCC using ECU Half-slip - a New Technique Institution where the work was prepared: Department of Orthopaedic Surgery, School of Medicine, Keio Univ, Tokyo, Japan Toshiyasu Nakamura, MD, PhD1; Hiroyasu Ikegami1; Kazuki Sato1; Noriaki Nakamichi1; Noriko Okuyama1; Shinichiro Takayama, MD, PhD2; (1)Keio University, (2)National Center for Child Health and Development Purpose: Since 1998, we treated 29 wrists of ulnar detachment of the TFCC by reconstruction technique using half-slip of the extensor carpi ulnaris (ECU) tendon. We described the technique of the reconstruction and examine clinical results of the procedure. Methods: There were 19 right, 8 left and 1 bilateral wrist with an average age of 34.8 years (range 13-68). All complained ulnar sided wrist pain and severe distal radioul- nar joint (DRUJ) instability. The neutral ulnar variance was indicated in 23 wrists and positive in 6. In the positive variance wrists, the ulnar shortening equal- ized the abutment before the reconstruction. Periods from initial injury was 1 month to 48 years. Diagnosis of the TFCC avulsion was done by arthrogram and MRI. Radiocarpal arthroscopy could demonstrate loss of trampoline effect in all wrists. DRUJ arthroscopy revealed detachment of the radioulnar ligament ori- gin at the fovea in recent 9 cases. The ECU half-slip was harvested and was induced inside the TFCC through the fovea area. The half-slip was tightly sutured to the remnant TFCC, then pulled out through the bone tunnel that was made at the center of the fovea by 2.5 mm diameter drill. The ECU half-slip was sub- sequently anchored to the ulnar fovea with the small interference screw. Two weeks long arm cast was occurred, followed by three weeks of short arm cast. Clinical results were evaluated by pain, range of rotation and DRUJ instability. Results: At final follow-up (average 21.5months), 26 wrists indicated no pain and slight pain remained in 3 wrists. Complete re-stabilization of the DRUJ was noted in 26 wrists, however there remained moderate DRUJ instability in 2 wrists. Severe DRUJ instability remained in 1 wrist. There were 25 excellent, 2 good, 1 fair and 1 poor results. Conclusions: This reconstruction technique represented real anatomical reattachment of the TFCC to the ulnar fovea, which induced excellent DRUJ stability and clinical result.

106 Mechanical Testing of Distal Radioulnar Instability Repair: Ligament Reconstruction vs Capsulorraphy Institution where the work was prepared: Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA Christopher J. Dy, BS, MD-Candidate; E. Anne Ouellette; Ali Malik; Veronica Diaz; Anna-Lena Makowski; Edward Milne; Andre Barreto; Loren Latta; Leonard M. Miller School of Medicine, University of Miami

Introduction: Instability of the distal radioulnar joint (DRUJ) presents a therapeutic challenge to physicians, with management varying according to the pathomechanics of the lesion. Extensive injury to the TFCC, the major stabilizing structure of the DRUJ, is increasingly repaired via radioulnar ligament reconstruction. An alter- native procedure, a capsulorraphy, has been proposed and used by the investigative team with clinical and biomechanical success. This study is a comparison of clinical and biomechanical stability following ligament reconstruction and capsulorraphy.

Methods: Nine fresh-frozen cadaver arms were examined using fluoroscopy and biomechanical testing. Ulnocarpal instability was reproduced by manual division of the dorsal and volar radioulnar ligaments, creating an ulnar-sided peripheral TFCC tear. The stability of the DRUJ was restored using the capsulorraphy in four specimens and anatomic ligament reconstruction in five specimens. All limbs were evaluated in pre-repair and post-repair conditions. Change in radioulnar stiffness was evaluated using the mechanical testing system.

Results: Both repair techniques resulted in a statistically significant increase in stiffness (p<0.05) when comparing pre-repair and post-repair radioulnar stiffness. When comparing the radioulnar stiffness ratios for each specimen before and after repair, there was no significant difference between the ligament reconstruction and the capsulorraphy.

Discussion/Conclusion: These results suggest that there is no statistically significant difference when comparing post-repair stiffness with the capsulorraphy procedure, which is a less invasive and less time-consuming repair, and an anatomic ligament reconstruction. Both techniques effectively restored DRUJ stability after pTFCC tear. Clinical comparisons are underway.

Does Thumb Immobilization Contribute to Scaphoid Fracture Stability? Institution where the work was prepared: Loma Linda University, Loma Linda, CA, USA J. Mark Schramm, MD; Minhthy Nguyen, BA; Montri D. Wongworawat, MD; Ingrid Kjellin, MD; Loma Linda University

Background: Nondisplaced scaphoid fractures can be immobilized in a variety of casts. Immobilization protocols have included the elbow, wrist, and thumb. Studies have demonstrated that below elbow casting is sufficient for most scaphoid fractures. This study attempts to demonstrate whether or not immobilization of the thumb makes a difference in preventing motion at the scaphoid fracture site.

Method: In a cadaveric model using 6 fresh frozen forearm specimens, a waist scaphoid fracture was created through a dorsal approach. Metallic markers were imbed- ded on either side of the fracture. Sutures were secured to the flexor pollicus longus (FPL) and extensor pollicus longus (EPL) in the proximal forearm. Flexion and extension forces were simulated by attaching 50 gram weights to the FPL and EPL, respectively. Each specimen was loaded in extension and flexion, (1) first with no casting, (2) then with a short arm cast, and (3) finally a short arm thumb spica cast. Angulation and displacement at the fracture site was meas- ured in the coronal, sagittal, and axial planes utilizing image reconstructions from a GE Lightspeed 16 detector CT scan with slice thickness 1.25mm. One-way ANOVA with repeated measures and Tukey-Kramer Multiple Comparison Test post-hoc analysis were used for statistical evaluation.

Results: The results are summarized in the Table. There was no significant difference in fracture angulation between spica and short arm casts. There was a signifi- cant difference in angulation in all three planes when comparing between casting and no casting: specifically varus/valgus angulation in the coronal plane, rotation in the axial plane, and flexion/extension in the sagittal plane, p < 0.05. There was no significant difference in displacement of the fracture fragments when comparing all immobilization methods.

Table: Results of Angulation/Rotation/Translation Based on Immobilization Type Parameter No cast Short arm cast Thumb spica Angulation-Rotation (deg ± SD) Varus-Valgus 30.5 ± 24.2* 10.8 ± 14.5 12.2 ± 21.5 Flexion-Extension 32.7 ± 20.0* 9.0 ± 6.7 5.2 ± 4.8 Axial Rotation 19.8 ± 12.0* 3.3 ± 2.3 2.7 ± 2.3 Translation (mm ± SD) Anterior-Posterior

0.2 ±=""

0.0 ±=""

0.0 ±="" 0.4="">

0.2> 0.0="">

0.0> 0.0="">

0.0> Medial-Lateral

0.3 ±=""

0.0 ±=""

0.0 ±="" 0.8="">

0.3> 0.0="">

0.0> 0.0="">

0.0> Proximal-Distal

0.3 ±=""

0.2 ±=""

0.2 ±="" 0.8="">

0.3> 0.4="">

0.2> 0.4="">

0.2> * significantly more angulation-rotation, p < 0.05 Conclusion: In our cadaveric model, short arm casting was just as effective as thumb spica casting to prevent angulation of scaphoid fractures in the presence of thumb extension and flexion.

107 Complications in Percutaneous Screw Fixation of Scaphoid Fractures Institution where the work was prepared: University of North Carolina Hospitals, Chapel Hill, NC, USA Brandon DuBose Bushnell, MD; Andrew McWilliams, MPH; Terry M. Messer, MD; University of North Carolina Hospitals

Introduction: With advances in tools and techniques, percutaneous screw fixation of nondisplaced or minimally-displaced fractures of the scaphoid has gained increasing popularity in recent years as an alternative to prolonged cast immobilization. Many reports cite very low complication rates, including no complications in some series. We present our experience with the technique and the complications we have encountered.

Materials/Methods: A retrospective chart review was performed on the 23 patients of the senior hand surgeon at a Level I trauma center who underwent surgery between October 2001 and March 2006. All cases involved dorsal percutaneous screw fixation of nondisplaced or minimally (<1mm) displaced fractures of the scaphoid waist or proximal pole.

Results: Of the 23 patients reviewed, 3 lacked adequate follow-up. Nineteen of the 20 remaining patients healed (95%), with one patient requiring revision surgery for nonunion. Average time until radiographic healing was 16 weeks. The overall complication rate was 25%, with 15% major complications and 10% minor com- plications. Major complications consisted of the one case of nonunion and two cases of painful hardware requiring removal. Minor complications included intraoperative equipment breakage – one case involving a screw and one case involving a guide wire. Smoking had a statistically significant effect on healing.

Conclusions/Discussion: Most of the complications we have experienced occurred early in our experience with this procedure, and almost all of them resulted from technical errors. Percutaneous screw fixation of scaphoid fractures can result in rapid, reliable healing, but the surgeon must meticulously adhere to proper technique to reduce the risk of complications.

The Use of Routine Radiography in the Evaluation of Ganglion Cysts of the Wrist Institution where the work was prepared: University of Michigan Hospital, Ann Arbor, MI, USA Andrew S. Wong, MD1; Peter J.L. Jebson1; Peter M. Murray, MD2; Stephen D. Trigg, MD2; (1)University of Michigan, (2)The Mayo Clinic

Ganglion cysts are the most common soft tissue tumor of the hand and wrist, with the most common sites being the volar and dorsal wrist. Diagnosis is pri- marily based on history and physical examination; however, the role of radiology is unclear. The objective of this study was to analyze the cost-effectiveness of routine radiography in the evaluation of ganglion cysts of the wrist. In the setting of a university-based hand surgery practice during a two year period, 103 consecutive patients who presented with a dorsal or volar wrist ganglion underwent PA and lateral radiographs of the affected wrist. The group included 24 males and 79 females, with a mean age of 34.1 years. We performed a retrospective study, reviewing the medical histories, physical examinations, radiologists' interpretations, and when applicable, pathology of excised tumors. Abnormalities on plain radiographs were noted in 13 patients (12.6%), including 6 cases of thumb carpometacarpal arthritis, and one case each of an enchondroma, congenital distal radioulnar joint (DRUJ) anomaly, DRUJ arthritis, intraosseous gan- glion of the capitate, carpal bossing, radiocarpal arthirits, and thumb metacarpophalangeal arthritis. In only 1 (1.0%) of these cases did plain radiographs alter the therapeutic decision. In our institution, the professional and technical costs of a PA and lateral view of the wrist is $172. This confers a cost of $17,716 per therapeutically significant finding in our series. We conclude that routine radiography is not cost-effective in the diagnosis and therapeutic decision-mak- ing process of ganglion cysts of the wrist.

Arthroscopic Management of Dorsal Wrist Ganglions Institution where the work was prepared: UCSF, Division of Plastic Surgery, San Francisco, CA, USA Amarjit S. Dosanjh; Scott L. Hansen, MD; Kyle Bickel, MD; UCSF

Objectives: Dorsal wrist ganglions are a common ailment and the mainstay of treatment remains open ganglionectomy. Arthroscopic management of dorsal wrist gan- glions has been recently described. We document our experience with arthroscopic excision of dorsal wrist ganglions.

Methods: 25 patients (mean age 40; range 25-71 years) underwent arthroscopic ganglion cyst excision over a 5-year period. All patients underwent diagnostic wrist arthroscopy. The stalk of the ganglion cyst and its communication with the joint was identified by probing a needle through the cyst and stalk. A shaver was introduced through the 3-4 portal and the stalk, as well as 1-1.5 cm of surrounding capsule, was excised.

Results: Of the 25 patients, 4 had previously failed aspiration and the rest had no pre-operative procedure. The time to presentation ranged from 1 week to 20 years. The primary complaint for all patients was pain. Two of the patients (8%) were noted to have a tear in their TFCC during arthroscopy and this was managed during the same operation. Twenty-two patients recovered uneventfully. Three patients (12%) had recurrence; one patient had resolution after aspiration and steroid injection, a second patient failed aspiration and steroid injection and required open excision and the third patient did not seek additional surgical man- agement. The mean follow-up was 2.3 years. Comparison with open excision is pending.

Conclusions: Arthroscopic resection of dorsal wrist ganglions can be safely and reliably done by routine arthroscopic techniques coupled with intra-articular identification of the stalk with a needle inserted through the cyst. In addition, arthroscopic management provides an opportunity to evaluate the articulating surfaces of the wrist and potentially manage additional sources of wrist pain/instability. We recommend routine management of ganglion cysts via an arthroscopic approach.

108 AAHS Poster Presentations

Upper Extremity Reconstruction with Radial Forearm Fascia Flaps Institution where the work was prepared: University of Washington, Seattle, WA, USA Jeffrey B. Friedrich, MD; Nicholas B. Vedder, MD; University of Washington

Introduction: The radial forearm flap has been an important development in upper extremity reconstruction. However, it is also known that the donor defect can be a source of significant morbidity. One method of donor management that has been put forth is use of a radial forearm fascia-only flap, leaving the donor site skin intact, with application of a split skin graft to cover the flap itself. We report our experience with the use of the radial forearm fascia flap for upper extremi- ty reconstruction.

Methods: A review of patients who underwent upper extremity reconstruction with a radial forearm flap was conducted. Records were analyzed for type of reconstruc- tion (fascia + skin graft versus fasciocutaneous), reconstruction complications, and donor site complications.

Results: Fourteen patients underwent radial forearm flap reconstruction from 1997 to 2005. Seven were fascia-only, seven fasciocutaneous. In all cases of fascia-only reconstruction, the flap contour was judged to be excellent, whereas some of the fasciocutaneous reconstructions were found to be bulky, requiring second- ary reduction. Additionally, the donor sites in the fascia-only group were judged to be of superior aesthetic quality. In the fascia group, there were no donor site complications, however, there was 1 partial skin graft loss on a flap, and 4 partial flap necroses. In the fasciocutaneous group, there were 2 episodes of skin graft loss on the donor site, and no full or partial flap losses.

Conclusions: While upper extremity reconstruction with a radial forearm fascia flap has the potential for donor improvement and improved contour of the flap compared with fasciocutaneous reconstructions, the flap itself can be more tenuous in the fascia-only reconstructions.

Post-Traumatic Ulnar Artery Pseudoaneurysms: A Report of Two Cases and Associated Complications Institution where the work was prepared: Albert Einstein Medical Center, Philadelphia, PA, USA Sue Y. Lee, MD1; Laurie Hirsh, MD1; James Raphael1; Minn Saing1; Rashad Choudry, MD2; Michael Salvatore, BS2; (1)Albert Einstein Medical Center, (2)Temple University Hospital

Introduction: Arterial pseudoaneurysm following upper extremity penetrating injury is a rare complication that is likely under-reported in the surgical literature. Ulnar artery pseudoaneurysms may present a serious threat to digit perfusion and hand function. Potential risks include pain, arterial disruption, symptomatic expansion, and ulnar nerve dysfunction. The close proximity of the ulnar nerve places it in jeopardy and the resulting neuropraxia is often the presenting complaint. Variations in arterial anatomy alter clinical presentations and ultimately may impact management. These lesions are often deceptively innocent at presenta- tion, but may have profound sequelae. To date, management is poorly defined in the literature. We recommend prompt surgical management to avoid devas- tating complications.

Cases: We reviewed two cases of ulnar artery pseudoaneurysm as a result of penetrating injuries to the upper extremity. The first patient suffered impalement of glass following a close proximity explosion. Development of a claw deformity secondary to intrinsic paralysis, increasing pain, and swelling prompted evaluation. A MR angiogram and duplex ultrasound confirmed the diagnosis and a patent palmar arch. The second patient sustained multiple gunshot wounds, including one to the right forearm. His injuries included a scapular fracture and diffuse brachial plexus injury, with dense anesthesia in the ulnar nerve distribution and no ulnar motor function. Evaluation confirmed complete arches distally with good perfusion. Spontaneous rupture occurred in the office during a routine fol- low-up examination.

Both patients underwent surgical exploration and resection of their respective lesions. At surgery, both ulnar nerves were explored and found to be intact. In the first case, resection of a large (6 cm) pseudoaneurysm was electively scheduled. The second patient required emergency resection of the ulnar artery pseudoaneurysm to prevent life-threatening arterial hemorrhage. Pre-operative clinical and radiographic evaluation proved useful in delineating the forearm anatomy and confirming the diagnosis. Both patients continue to have significant ulnar nerve dysfunction at latest follow up.

Discussion: The natural history of upper extremity pseudoaneurysms remains unpredictable. They should be carefully evaluated clinically prior to surgical treatment. A num- ber of available imaging techniques can assist in pre-operative localization and diagnosis. Due to the close proximity of the ulnar nerve and potential for life- threatening hemorrhage, we support operative treatment in all cases. Repair or ligation should be performed in all patients to minimize the risks of compres- sive nerve injury, subsequent hand deformity and dysfunction, and spontaneous rupture.

(Arteriograms, duplex ultrasound, and intraoperative images available and to be included.)

109 Re-do Digital Sympathectomy in Refractory Raynaud's Phenomenon Institution where the work was prepared: University of Chicago, Chicago, IL, USA Amir H. Dorafshar, MBChB; Iris A. Seitz, MD, PhD; Lawerence S. Zachary, MD; University of Chicago

Background: Digital Sympathectomy (DS) has been described as an efficacious method in the treatment of Raynaud' phenomenon. However, some patients develop severe symptoms of recurrent pain, limitations of functional activity, cold sensitivity and recurrent ulcerations many years after their initial procedure. Redo Digital Sympathectomy (RDS) has been previously theorized in the literature as a useful treatment option for patients with refractory Raynaud's phenomenon (RRP) but outcome has only been documented in one patient's finger. Here, we present our experience of RDS in the treatment of RRP.

Hypothesis: RDS would provide patients with RRP improvement in the severity of symptoms, functional activity, cold sensitivity and ulceration healing.

Specific Aims: To assess the efficacy and role of RDS of patients with RRP with respect to severity of symptoms, functional activity, cold sensitivity and ulceration healing.

Methods: Patients who failed non-surgical treatment for RRP undergoing RDS between 1995 and 2005 were evaluated. A retrospective chart review and telephone patient survey of patient demographics, previous therapeutic interventions and postoperative outcomes were performed. Severity of symptoms, functional activity, cold sensitivity and the healing of ulcerations were surveyed.

Results: Three female patients, age 34-64 (average 49) with RRP underwent RDS on a total of 8 fingers (7 fingers had single RDS, 1 finger had 3 re-do RDS). Average time to recurrence of symptoms after the initial DS was 6 years (range 2-8) and the duration of symptoms until RDS was performed was 41 weeks (range 6- 104). After an average follow up of 1 year after the RDS for 16 fingers, all patients reported improvement in severity of symptoms (Levine Symptom Severity Scale 3.5 vs. 1.7 (range 1-5)), cold sensitivity (McCabe Cold Sensitivity Scale 354 vs. 120 (range 0-400)) and functional activity (Functional Activity Scale 3.7 vs. 2.5 (range 1-5)) in the affected fingers when comparing pre vs. post RDS. 7 fingers had preoperative ulcerations that were completely healed postopera- tively at an average of 3 months. All patients were very satisfied with the results of surgery and all would recommend surgery for treatment of RRP.

Conclusion: Patients with severe recurrent RRP after previous DS may benefit from RDS as a surgical treatment option to improve symptom severity, functional activity, cold sensitivity and ulcer healing. Denervation and decompression of scar tissue surrounding the digital arteries may provide an explanation for the mecha- nism of enhanced blood flow to the fingers in these severely affected patients.

Complications of Adjuvant Radiation for Soft Tissue Sarcomas of the Hand Institution where the work was prepared: Memorial Sloan Kettering Cancer Center, New York, NY, USA Rachel S. Rohde, MD1; Carol Morris, MD2; Patrick Boland2; John H. Healey2; Edward A. Athanasian2; (1)Hospital for Special Surgery, (2)Memorial Sloan Kettering Cancer Center

Risks of adjuvant radiation therapy (RT) to improve local control and hand sparing surgical options in the treatment of soft tissue sarcoma of the hand (STSH) are not well characterized. The compact nature of functional tissues and limited tissue volumes might predispose to complications which result in significant functional impairment.

Purpose: To determine the risk of hand-specific complications, predictive factors and relation to radiation timing following treatment of STSH with RT.

Methods: A retrospective chart review of 55 patients treated surgically for STSH was performed. Data regarding presentation, comorbidities, diagnosis, treatment, and outcome including complications were analyzed.

Results: Twenty-six of the 55 patients had undergone RT. Twenty-nine treatment-related complications occurred in 19/26 patients who had received RT (73%) com- pared to 3/29 patients treated without RT (10%). All who received brachytherapy and 14/23 (61%) treated with external beam irradiation alone had compli- cations. Preoperative and postoperative RT complication rates were 75 and 72%, respectively.

Conclusions: Adjuvant RT of STSH was associated with increased complications. Risk was greatest when brachytherapy was used adjacent to joints. A better understanding of predictors of complications will be beneficial in determining timing and type of RT used to treat STSH.

110 Predicting the Development of Upper Extremity Compartment Syndrome in Traumatic Brachial Artery Injuries: A Retrospective Analysis Institution where the work was prepared: Northwestern Memorial Hospital, Chicago, IL, USA Clark Friedrich Schierle, MD, PhD; Northwestern University; John Y.S. Kim, MD; UT M. D. Anderson Cancer Center

Background: A sequelae of brachial artery injury in the setting of upper extremity trauma is the development of compartment syndrome (CS). A high index of clinical suspicion for CS is needed.

Methods: We performed a retrospective review of 139 trauma patients with brachial artery injury from 1985-2001. The variables observed were: age, sex, ethnicity, mech- anism and severity of injury, presence of concomitant trauma, total ischemic time, intra-operative blood loss, hemodynamic instability and signs of distal per- fusion. Multivariate logistic regression explored predictive factors for development of compartment syndrome.

Results: Shock (p=0.03), combined artery injury (p=0.03), bone fracture (p=0.02), open fracture (p=0.01), combined nerve injury (p=0.02), operative time in minutes (p=0.0007) and intra-operative total blood loss in 100mL (p=0.001) appear to be significantly associated with the development of CS after univariate analysis. Only 3 variables were significant after multivariate analysis: Intra-operative blood loss in 100mL appeared to be significantly positively correlated to the CS (p=0.0003), having combined artery injury was marginally significant (p=0.05), and having open fracture was marginally significant (p=0.10) as well. Odds ratio were 1.12, 5.79 and 2.68 respectively. We used all three significant variables in the final adjusted model to create a summative score for the development of CS with weights assigned proportional to the adjusted odds ratio. Odds of having compartment syndrome for subjects in group 2 and group 3 are 5.3 and 15.1 times the odds for subjects in group 1, respectively.

Conclusion: We have successfully established an easy summative score model to assess the risk of developing CS.

Avascular Necrosis of the Fourth Metacarpal Head Presenting in a Delayed Fashion After Successful Treatment of Adjacent Fifth Metacarpal Fracture: A Report of Two Cases Institution where the work was prepared: Orthopedic and Sports Medicine, Annapolis, MD, USA Dan Hatef, MD; UT Southwestern; Jeffrey Gelfand, MD; Orthopedic and Sports Medicine

Purpose: Boxer's fracture is one of the most common fractures treated by hand surgeons. In patients who have less than 30 degrees of dorsal angulation and no mal- rotation, conservative treatment is usually acceptable. Commonly reported complications are non-union, malunion, rotational deformity, and functional deficit. To date, no authors have reported a case of avascular necrosis of the fourth metacarpal head secondary to a Boxer's fracture.

Methods: Two patients who sustained fifth metacarpal fractures are presented. One patient suffered his injury striking a tree, the other patient suffered his injury dur- ing volleyball when he struck the ball with a closed fist. Both patients were initially treated with casting followed by early range of motion. Both patients pre- sented at least 6 months after injury with new symptoms of pain in the palm over the area of the adjacent fourth metacarpal head. Radiographs obtained revealed evidence of avascular necrosis of the fourth metacarpal head with complete healing of the previously injured fifth metacarpal. One patient had mechan- ical symptoms and radiographic appearance of a loose osteochondral flap, he was managed operatively with absorbable pin fixation of the loose fragment. The other patient was observed conservatively with periodic radiographs.

Results: Both patients had clinical resolution of symptoms. Serial radiographs suggest revascularization with evidence of remodeling of the lesions and no further evi- dence of collapse.

Conclusions: We report the first two cases of avascular necrosis presenting in a delayed fashion in the metacarpal head adjacent to a previously fractured fifth metacarpal. Suspicion should be raised in patients presenting with delayed onset of pain after successful treatment of a fifth metacarpal fracture and appropriate imaging studies should be performed to evaluate the possibility of avascular necrosis.

111 Flexor Digitorum Profundus Repair to Bone: A Biomechanical Comparison Institution where the work was prepared: University of New Mexico, Albuquerque, NM, USA Deana Mercer; keikhosrow firoozbakhsh; jenifer fitzpatrick; moheb moneim; University of New Mexico

Purpose: Treatment of distal flexor digitorum profundus injuries presents a challenge to the orthopaedic surgeon. Presently available techniques for repair of flexor dig- itorum profundus tendon injuries include button or suture anchor fixation. This study evaluates a newly proposed absorbable suture anchor and compares it to techniques using non-absorbable suture anchor of comparable size and button fixation.

Methods: Fifteen fresh-frozen cadaveric hands were used. The index, long, and ring finger were harvested for testing. Fifteen digits were randomly assigned to each of the three fixation techniques. Tendon-to-bone repair was done using the button, absorbable suture anchor, and non-absorbable suture anchor technique. Specimens were tested to failure using the Bionex-MTS system. Mode of failure and force to failure of fixation was recorded and statistically analyzed.

Results: Force to failure was not significantly different among the three fixation techniques (p>0.05). The mode of failure for the button technique was suture pull- out through tendon (100%). The mode of failure for the absorbable suture anchor was rupture at the anchor-suture interface (80%) and anchor pull-out (20%). The mode of failure for the non-absorbable suture anchor was suture pull-out through the tendon (60%) and rupture at the anchor-suture interface (40%).

Discussion: Bone quality, bone-anchor interface, and suture material play an important role in fixation strength. An insight to the mode of failure suggests that the best fixation technique in osteoporotic bone is the button technique or the non-absorbable suture anchor.

A New Scoring System for Assessing Severity in Dupuytren's Disease Institution where the work was prepared: University of Manchester, Manchester, United Kingdom Sandip Hindocha, MBChB; John K. Stanley, MCh, Orth, FRCS; Stewart J. Watson, MRCP, FRCS; Ardeshir Bayat, MD, PhD; University of Manchester

Many factors have been associated with severity in Dupuytren's disease (DD). Previous methods to assess severity of DD are based on the degree of contrac- ture of an affected digit. We feel these methods of assessment may be incomplete and that other factors should be considered. We aim to devise a new scor- ing system, which can quantify the severity of DD to predict post-operative outcome. Caucasian patients diagnosed with DD (n=92) from Northwest England were assessed for DD. Criteria for evaluating severity incorporated quantified variables including; age at onset, bilateral and ectopic disease, family history, frequency of and recurrence following surgery, number of digits affected and combined total flexion deformity (TFD) of all digits. Severity scores were correlated to a known staging system of DD TFD for a single affected digit. Total severity score ranged between 3 and 37 (mean=14.1, SD=7.9) and revealed significant positive correlation to a known staging system (r=0.8, p<0.001). Previously degree of contracture in an affected digit was used to predict surgical outcome. It is evident from this study that other factors should also be con- sidered when grading severity that may influence post-operative results. Thus a new severity scoring system for DD has been introduced.

Severe Peripheral Vascular Disease of the Upper Extremities. A case study Institution where the work was prepared: Providence Hospital/Mayaguez Medical Center, Southfield, MI, USA Gustavo E. Bello-Rojas, MD; Providence Hospital

Extensive upper extremity tissue loss usually results from atherosclerotic, vascular disorders or distal thromboembolic events. This then becomes a challenge for the vascular and hand surgeons. Salvage procedures such as in-situ vein grafting, arteriovenous reversal or proximal to distal by-pass procedures are necessary. A 55 year-old female with a history of insulin-dependent diabetes mellitus, chronic renal failure and chronic hypertension presented with sudden onset of pain in both upper extremities with necrosis of the 3rd right digit and the 3rd and 4th left digits. There was no evidence of infection but necrosis extended to the proximal phalanx. Distal pulses were absent bilaterally. A bilateral upper extremity angiogram showed occlusion of the ulnar and radial arteries with dilatation of the superficial palmar archers. Reversed saphenous vein grafts were used as conduits in both extremities. A right brachial to ulnar artery bypass was performed initially and four weeks later a left brachial to radial bypass was performed. Both bypasses were anastomosed distally close to the origin of the corresponding arch. Her postoperative progress was uneventful. Finger systolic pressures were measured and this showed significant improvement of flow. Areas of necrosis become demarcated and the affect- ed digits were amputated several weeks later. At three months, graft patency was evaluated with an angiogram of the upper extremities, and flow to both deep palmar arches was confirmed. Chronic severe ischemia of the upper extremity is a rare entity because of the collateral network of the limb. Compared to the lower extremity, arterial recon- struction of the upper extremity is rarely performed. There are few publications regarding bypass grafting of the upper extremity and its long-term results. Though ischemia of the upper extremity is a known entity, treatment guidelines for the condition are ill defined, and a standard of care does not exist. Traditional treatment of proximal vessel disease involves bypass, endarterectomy, balloon angioplasty and stenting. However, distal vessel occlusions were con- sidered not to be amenable to direct operative treatment. The result of this case suggests that distal upper extremity occlusions can be treated by distal revascularization procedures. This is recommended as a salvage procedure.

112 Lymphangioma of the Finger in Children: Two Case Reports and Literature Review Institution where the work was prepared: Grand Rapids Orthopaedic Residency, Michigan Hand Center, Grand Rapids (Michigan State Unicersity), MI, USA Christopher M. Dolan, M, D; Grand Rapids Medical Education and Research Center Michigan State University; Julian Kuz, MD; Michigan State University

Introduction Lymphangioma of the finger is a rare and challenging congenital tumor, the treatment of which is not well standardized. Our review of the literature found only four reported cases involving the finger and these were included within two larger case series. This report describes two children with recurrent lymphangioma of the finger and discusses the diagnosis, pathogenesis, and treatment of this rare upper extremity disease. Cases Two healthy two year old children presented with a non- painful enlarging mass involving the radial mid-lateral aspect of the middle phalanx of the right index and middle finger respectively. The masses were firm, non-ten- der, non-mobile and 7-8 mm in diameter. Range-of-motion, sensation, and tendon function was normal. X-rays demonstrated no soft tissue calcification, osteolysis, or deformity. MRI of Case 1 revealed a lesion with indistinct borders in close proximity to the radial neurovascular bundle. During excisional biopsies, only marginal excisions could be obtained without excising vital adjacent structures. Pathology results were consistent with lymphangioma. The masses recurred at six and seven months respectively. One recurrence associated with pain underwent a repeat excision. Pathology confirmed the diagnosis of recurrent or residual lymphangioma. After 9 months, the mass recurred a second time. After two years, both patients are free of pain and functional deficits. Discussion Lymphangioma is the least common vas- cular tumor of the hand. It is a congenital benign neoplastic proliferation of lymphatic channels that presents as a soft tissue mass usually in infants or shortly after birth. Treatment in the hand can be extremely difficult secondary to the tumor's invasive characteristics and proximity to delicate vital structures of the musculoskele- tal and neurovascular system. Imaging studies offer little help in delineating tumor margins. This invasive tendency makes complete excision difficult and leads to a high local recurrence rate. Diagnosis is based on the predominant tissue type from biopsy. Conclusion In spite of the associated surgical difficulties, operative excision is the only treatment choice for lymphangioma of the hand and method of preventing gradual tumor enlargement. We recommend early and as complete excision of the tumor as possible. Initial and all subsequent excisions and biopsies should undergo histological analysis. We suggest early repeat surgical excision for enlarging tumors associated with pain or functional limiting characteristics. Image Dilated endothelial-lined channels contain fine, amorphous eosinophilic material in the origi- nal excision from Patient 1; these features characterize lymphangioma. 100X magnification of hematoxylin and eosin stained section.

The Value of Routine Use of Radiographs for Dorsal Wrist Ganglions Institution where the work was prepared: Medical Education and Research Center, Grand Rapids, MI, USA Derek Johnson, MD; Grand Rapids Medical Education and Research Center; Julian Kuz, MD; Michigan State University

Title: The Value of Routine Use of Radiographs for Dorsal Wrist Ganglions Summary: Reviewing the routine use of radiographs in the evaluation of 102 patients with dorsal wrist ganglions indicates that the practice is costly and unlikely to change the management in this population. Introduction: Dorsal wrist ganglions are common diagnoses for Orthopaedic Surgeons with a referral incidence of 55 per 100,000, or 165,000 per year. Despite their characteristic appearance and location, it is common to include routine wrist radiographs in the initial evaluation. It is our objective to evaluate cost and benefit of this practice. Methods: In a community based hand practice, a retrospective chart review of 102 patients with confirmed diagnosis of dorsal wrist ganglion was performed. Data points collected were age, gender, side of ganglia, hand of dominance, history of trauma, history of malignancy, range of motion, and radiographic and pathologic results. Results: One hundred two patients had confirmed dorsal wrist ganglion on aspiration or excision. Of those, 13 (12.7%) had positive radiographic findings, of which seven had previously known findings. Of the remaining six patients with new radiographic findings, none had their clinical management altered secondary to the findings. Discussion: Despite the ease of diagnosis, many surgeons use routine wrist radiographs as a screening exam in dorsal wrist ganglions. This practice in 102 patients failed to alter the treatment for any patient. With cost per radiograph ranging from $28.94 (Medicare reimbursement) to $72.00 (our institution fees) the cost per positive radi- ographic finding ranged from $227.07 to $564.92, with a total cost of $2951.88 to $7344. With an incidence of 165,000 per year, the total cost of this practice would range from $4,775,000 to $11,880,000. The clinician should be aware of the significant cost and low odds of altering their treatment with this practice.

The Use of an Innovative Device for Wound Closure after Upper Extremity Fasciotomy Institution where the work was prepared: Temple University Hospital, Philadelphia, PA, USA Carlos Medina; Julia Spears; Avir Mitra; John Gaughan; John Roussalis; Patricia Chavez; Amitabha Mitra; Temple University

The usual postoperative management of fasciotomy wounds of the upper extremity consists of delayed primary closure but tissue edema and friability often makes this difficult. The purpose of this paper is to evaluate the Silver Bullet Wound Closure Device (SBWCD, Boehringer Laboratories, Norristown, PA), a new device for delayed primary closure of fasciotomy wounds. A retrospective review was performed over a period of 36 months (January 2003-January2006) of all patients with an upper extremity fasciotomy wound that could not be closed primarily. Demographic data was collected along with clinical information regarding each patient. Cases that underwent fasciotomy closure with the SBWCD were separated from the patients that had a split thickness skin graft (STSG). Statistical analysis was performed using the Fisher's Exact Test and T-Tests. A total of 14 patients had their fasciotomy wound closure managed either with the SBWCD or a STSG. Eight patients had their wound closed with the Silver Bullet Wound Closure Device within 10 days (mean of 7.5 days). Six patients had their wound close with a STSG in an average 8.0 days. We were unable to appreciate a significant difference between the closure times for the SBWCD and STSG. The average number of days between the day of the fasciotomy incision and the date of the placement of the SBWCD was 2.3 days. STSG were placed on the fasciotomy wounds on an average of 9.6 days after the date of the fascioto- my incision. The difference between the two means was statistically significant. We found that the SBWCD allowed for starting to approximate the edges of the fasciotomy wound at an earlier time when compared to STSG (2.3 days vs. 9.6 days). We feel that the SBWCD as a one stage procedure provides a consistent and efficacious way to manage upper extremity fasciotomy wounds while minimizing the morbidity associated with STSG (pain at the donor site, creation of an additional wound, muscle to tendon adhesions, insensate skin over the fasciotomy site, poor cosmetic results). Elimination of a second stage procedure reduces hospital costs. Our findings at Temple University Hospital may help to inform surgeons about an available alternative when an upper extremity fasciotomy wound is not amenable to primary closure.

113 Unmasking the Flexor Digitorum Superficialis Decussation: Masquerading as a Supplemental Pulley Institution where the work was prepared: Union Memorial Hospital, Baltimore, MD, USA Michele A. Manahan, MD1; Sione Fanua, MSM2; Christina Hughes, MD2; Shaw Wilgis, MD2; (1)Johns Hopkins University School of Medicine, (2)Union Memorial Hospital

Introduction: Flexor digitorum profundus (FDP) lacerations and ruptures of zone 1 near the distal interphalangeal (DIP) joint are common injuries but demonstrate variable anatomy. In some cases, the vinculae hold the FDP in its anatomical position within the flexor digitorum superficialis (FDS) decussation distally, and deep to the FDS tendon more proximally. In other cases, the FDP retracts toward the palm. Accepted repair techniques of retracted tendons and tendon grafts include either reestablishing the FDP's anatomic positioning or allowing the FDP to travel alongside the FDS within the pulley system of the finger.

Methods: To determine whether pursuance of the often technically more difficult placement of the FDP within its native sheath translates into clinical advantages regard- ing extent of flexion of the DIP joint, we performed dissections on the four fingers of nine cadaver hands for a total of 36 digits. A laceration was created in the FDP tendon at its insertion in the distal phalanx. The FDP's vinculae and attachments were stripped proximally to a level proximal to the A1 pulley. The FDP tendons in half of the digits were replaced beneath the FDS and through the decussation prior to repair of the laceration with standard Bunnell's suture technique. The other half of the digits received suture repair after placement of the FDP through the digital pulley system beside the FDS. The digits were flexed using a standard weight system, and range of motion at the DIP joints were measured.

Results: Average range of motion at the DIP joints of control digits prior to dissection were 37°, 60°, 57°, and 50° for the index, long, ring, and small digits, respec- tively, with an overall average of 51°. Average range of DIP joint motion of the nonanatomic repairs were 43°, 59°, 62°, and 51° for the index, long, ring, and small digits respectively, with an overall average of 54°. Average range of DIP joint motion of the anatomic repairs were 29°, 47°, 35°, and 65° for the index, long, ring, and small digits, respectively, with an overall average of 44°.

Discussion: Although the ranges of motion for the anatomical repairs were actually less than the nonanatomical repairs in all digits but the small finger, no results reached statistical significance. It appears that the additional difficulty of anatomical replacement of the FDP through the FDS decussation does not improve function- ing, at least in a cadaver model.

Evaluating Fractures of the Distal Radius Articular Surface Using a CT Coordinate Grid-System—A Technique to Describe Fracture Patterns Institution where the work prepared: Department of Orthopedic Surgery and Rehabilitation, Texas Tech, El Paso, TX, USA Miguel Pirela-Cruz, MD; Solange Burnette, MD; Syeda T. Nargis, MBBS, MPH

Evaluation of the fractured articular surface of the distal radius using conventional radiographs is difficult. A numbered coordinate (grid) system that is super- imposed on a CT image is introduced to help in describing the configuration and location of the fracture pattern to minimize the problems associated with fracture interpretation. This information has potential use in clinical and investigational applications in addressing fractures of the distal radius.The specificity of the description can be tailored to the needs of the observer. The location of fracture lines, fracture fragments, and voids involving the articular surface of the distal radius can now be described using this system.s

Treatment of Paralysis of the Trapezius Following Injury to Spinal Accessory Nerve Institution where the work prepared: Boston University School of Medicine, Boston, MA, USA Harilaos T. Sakellarides, MD, Orthopaedic/Hand Service, Boston University School of Medicine, 3 Hawthorne Place (S-102), Boston, MA, USA

Ten cases with paralysis of the trapezius muscle have been treated in the past 25 years. Most cases were the results of accidental injuries. Half were of iatro- genic origin, namely paralysis followed the removal of small lipomas from the neck area. There were ten patients, six men and four women. The right side was involved six times, the left four times. Ages ranged from 28 to 65 years. All patients were handicapped in using their extremities, causing marked weakness in abduction, with difficulty performing activities such as fishing, tennis, golf and other sports, as well as simple tasks like combing their hair, putting hand behind neck and elevating the arm. The operation consisted of transferring the insertion of the levator scapulae with a fascial sling through the acromion. The fascial sling was also used to anchor the spinal border of the scapula to the spinous processes of the upper dorsal vertebrae. The lateral transfer of the rhomboid mus- cle in a double-breasted fashion, was added to this procedure. The results were as follows- excellent and good 75% and fair 25%. In this group, all patients demonstrated much improvement compared with the preoperative status. This method has been found to be satisfactory for correcting the paralysis of the trapezius.

114 AAHS/ASRM/ASPN Outstanding Nerve Papers

Comparison of Return to Work: Endoscopic Cubital Tunnel Release versus Anterior Subcutaneous Transposition of the Ulnar Nerve Institution where the work was prepared: Orthopaedic Specialists, Davenport, IA, USA TYSON Cobb, MD; Patrick T Sterbank, PA-C; ORTHOPAEDIC SPECIALISTS, P.C

Endoscopic Cubital Tunnel Release (ECTR) is an emerging technique with speculated advantage of a smaller incision and earlier return to activity. Several ear- lier studies have demonstrated clinical efficacy of ECTR but early return to activity has not been clearly documented. The purpose of the study was to com- pare the return to work time for patients undergoing ECTR versus Anterior Subcutaneous Transposition of the Ulnar Nerve (ASTUN).

METHODS: A retrospective review of 30 consecutive cases was used to determine the time from surgery to return to work. Follow-up time averaged one year for both groups. All patients had electrical studies prior to surgery. All patients had positive Tinel's and Elbow Flexion test. Severity of symptoms was rated preopera- tively using Dellon's classification. Postoperative results were graded using Bishop 12 point rating system.

The ECTR study group consisted of 15 patients, 6 females and 9 males, 11 workmen's compensation and 4 group insurance; average age was 49 years, range 28 to 69. Dominant side surgery occurred in 8 cases (54%). Average length of preoperative symptoms was 26 months. 10 (68%) patients had a positive elec- trical study for Cubital Tunnel. Preoperative symptoms based on Dellon's classification were 10% Mild, 60% Moderate and 30% Severe.

The ASTUN group consisted of 5 males and 10 females, 12 involved workmen's compensation and 3 private insurance, average age was 44 years, range 23 to 57. Dominant side surgery occurred in 9 cases (60%). The average length of preoperative symptoms was 28 months. 9 (60%) patients had positive electrical studies for Cubital Tunnel. Preoperative symptoms based on Dellon's classification was 7% Mild, 63% Moderate and 30% Severe.

RESULTS: The ECTR results were 10 (68%) Excellent, 3 (20%) Good, 1 (6%) Fair and 1(6%) Poor utilizing the Bishop12 point rating system. The average return to mod- ified work was 2 days (range 1 to 3) and to regular work 7 days (range 5 to 9).

The ASTUN group average return to modified work was 17 days (range 12 to 22) and for full duty 70 days (range 60 to 80). Results based on the Bishop 12 point rating system was 10% Excellent, 62% Good, 22% Fair and 6% Poor.

All patients returned to their usual preoperative activities.

CONCLUSION: Endoscopic Cubital tunnel release provides good to excellent symptom relief in most patients with an earlier return to activity compared to ASTUN. The dif- ferences in recurrence, complications, and long-term outcome require additional study.

A Detailed Cost and Efficiency Analysis of Performing Carpal Tunnel Surgery in the Main Operating Room Versus the Ambulatory Setting Institution where the work was prepared: Dalhousie University / Saint John Regional Hospital, Saint John, NB, Canada Martin R. LeBlanc, BSc, MD; Janice Lalonde, RN; Donald H. Lalonde, BSc, MSc, MD; Dalhousie University

Objectives: Our goal was to analyze the cost and efficiency associated with performing carpal tunnel release (CTR) in the main operating room versus the ambulatory set- ting. We sent out a survey to members of the Canadian Society of Plastic Surgeons to document the venue of carpal tunnel surgery practices in Canada. Methods: A detailed analysis of the salaries of each involved person and the cost of materials involved in CTR performed in the main operating room versus the ambu- latory setting was done. A survey was emailed to practicing plastic surgeons in Canada to determine the venue of CTR performed by most of the surgeons. Results: For a standard 3 hour surgical block, we are able to perform 9 CTR in the ambulatory setting vs. 4 operations in the main operating room. The calculated cost of performing CTR in the office setting is $296/case ($2664/9 cases), $333 ($3000/9 cases) in our clinic, and $401 ($3606/9 cases) in the main operating room. All of these costs assume use of local anesthesia with no sedation and no tourniquet (wide awake approach). Our survey demonstrated that 18% of respondents used the main operating room exclusively for CTR, while 63% used this setting for some of their CTR. The ambulatory setting was used exclusive- ly for CTR cases by 37% and 69% used this type of setting for greater than 95% of their cases. Most surgeons, 75%, did greater than 50 cases of CTR a year. Conclusion: It would seem logical that CTR can be performed in an ambulatory setting at a reduced cost when compared to performing CTR in the main operating room. Our findings confirm this, and demonstrated a $105 per case maximum differential between CTR performed in an ambulatory setting versus the main operat- ing room. Even more importantly, we are only capable of performing 4 CTRs in the main operating room versus 9 CTRs in the ambulatory setting for a 3 hour standard surgical block. Therefore, less than half the numbers of patients are treated in the main operating room in the same time invested in the ambulato- ry setting. The use of the main operating room for CTR is more expensive, and less than half as efficient as CTR in an ambulatory setting. Our survey also demonstrated that many surgeons in Canada continue to use the more expensive, less efficient venue of the main operating room for CTR.

115 The Genetic Modification of the Human Sural Nerve Using Lentiviral Vectors Institution where the work was prepared: Netherlands Institute for Neuroscience, Amsterdam, Netherlands Martijn R. Tannemaat, MD1; Gerard J Boer1; Joost Verhaagen1; Martijn J.A. Malessy2; (1)Netherlands Institute for Neuroscience, (2)Leiden University Medical Center

In severe peripheral nerve lesions, autologous nerve grafts are used to bridge the gap between proximal and distal stumps. Recovery of nerve function after grafting is rarely complete. It is widely believed that nerve surgical repair in itself has reached an optimal level of technical refinement. Therefore, new adju- vant strategies to promote peripheral nerve regeneration following trauma and repair are needed.

promoting properties. Exogenously applied neurotrophic factors including nerve growth factor (NGF) have the potential of enhancing regeneration, but thus far their application has been limited by poor penetration in nervous tissue and fast degradation following local application. These problems may be overcome with the use of lentiviral (LV) vectors, which have been shown to be non-toxic and direct long-term transgene expression.

We therefore studied the optimal technique for transduction of the sural nerve with a lentiviral vector. Fresh Sural nerves were either submerged in a solution containing an LV vector encoding Green Fluorescent Protein (LV-GFP) at different incubation times or injected with LV-GFP with a glass capillary. Nerve pieces were kept in culture for an additional 3 days to allow transgene expression to develop. Transduction efficiency was evaluated by observing the number of GFP- positive cells. Direct injection proved the most effective method, as large numbers of cells inside the sural nerve pieces were transduced. Immunohistochemistry revealed that the majority of transduced cells were fibroblasts surrounding the nerve fascicles, although some transduced Schwann cells could also be seen. The injection of an LV vector encoding Nerve Growth Factor (LV-NGF) led to a significant increase of NGF production and secretion by cultured sural nerve pieces. To assess biological activity, culture medium of human fibroblasts previously infected with LV-NGF was applied to rat E15 dorsal root ganglions (DRGs). Computerised quantification of neurite outgrowth after 48 hours revealed a significant increase in neurite outgrowth in DRGs cultured in medium from LV- NGF transduced fibroblasts as compared to non- transduced fibroblasts. These results demonstrate that the NGF produced by human fibroblasts is biological- ly active and can stimulate neurite outgrowth in vitro.

Our experiments suggest that gene transfer for neurotrophic factors holds promise as a powerful novel adjuvant therapy for clinical peripheral nerve reconstruction.

A Comparison Study Between Single, Double or Triple Nerve Transfer for Shoulder Abduction in Avulsed Brachial Plexus Injury: Revisiting after 1000 Case Experiences Institution where the work was prepared: Chang Gung University Hospital, Taoyuan, Taiwan Alexander Cardenas-Mejia, MD1; Kuang-Te Chen, MD2; David CC Chuang2; Yu-Te Lin, MD3; ; (1)Chang Gung University Hospital, (2)Chang-Gung Memorial Hospital, (3)Chang Gung Memorial Hospital

Neurotization has probed to be superior to tendon or muscle transfer and arthrodesis in the adult avulsed brachial plexus injury(BPI). Our previous study (Plast Reconstr Surg 1995; 96:122-128) demonstrated that simultaneous neurotization of both suprascapular(SS) and axillary nerves provided better and more reli- able shoulder abduction than single nerve neurotization. However, we also showed that the use of a single nerve transfer is capable of producing adequate results. A retrospectively study in the last three years was made of 207 cases with BPI after completion 1000 cases of adult brachial plexus reconstruction expe- riences. Decision making, surgical techniques and postoperative rehabilitation during this study period were refined. We compared the results obtained with single, double or triple nerve transfer for shoulder reconstruction in order to establish which technique produced the optimal results. Between January 2000 and December 2003, 207 patients with BPI were treated at Chang Gung Memorial Hospital by the senior surgeon (DCC Chuang). Only 91 cases (with 2 years follow-up) that had nerve transfer (intraplexus or extraplexus) for shoulder abduction were analized. The majority of the injuries were caused by motorcycle accident (93.4%). The BPI involved total root avulsion in 8 patients, C5 and/or C6 root injuries in 41 patients and C5, C6 and C7 root injuries in 42 patients. The donor nerves used phrenic(ph), spinal accesory nerve(XI), proximal C5, posterior division upper trunk(PDUT), C6, contralateral C7(C7c) and cervical motor branch(CMB). The recipient nerves were distal C5 or PDUT, suprascapular nerve(SS), posterior cord(PC) and axillary nerve. 40 patients(43.95%) had single nerve transfer. 48 patients(52.74%) had double nerve transfers and 3 patients(3.31%) had triple nerve transfers. The ANOVA test was used for statistical analysis for comparison of the results. The average degrees of shoulder abduction obtained was 180º following triple nerve transfers (ph+XI+CMB transfers), 86.8º after double nerve transfers and 68.83º after single nerve transfer (p=0.08). In the single neurotization group, transfer of ph or XI produced similar results (average 75.71º vs 73º) with no statistical difference (p=0.89). In the double neurotization group ph to SS and C5 to PDUT transfer yielded better results than ph to PDUT and XI to SS transfer (average 99.23º vs 75º) although this was not statistically significant (p=0.26). In the triple nerve neurotization all the patients achieved full shoulder abduction. The results demonstrated that the use of a higher number of nerve transfers produced better and more reliable results.

116 Cross Facial Nerve Grafting for Facial Paralysis with Incomplete Recovery Institution where the work was prepared: National Taiwan University Hospital, Taipei, Taiwan Yueh-Bih Chen Tang, MD, Ph, D1; Hui-Hsiu Chang, resident1; Hung-Chi Chen, MD, FACS2; (1)National Taiwan University Hospital, (2)E-da/I-I Shou University Hospital

Facial palsy with partial or incomplete recovery is not infrequently seen among patients. Weakness at the muscles for facial expression is usually noticeable albeit it's incomplete. The patients usually look for possible corrections. In this group of patients, 52 cross facial nerve grafting from sural nerve to reanimate facial expression has been conducted in our center since 20 years ago. The age of the patients ranged from 18 years to 42 years, averaging 28 years. The har- vested sural nerve was anastomosed to either marginal mandibular nerve ( 25 patients) or buccal branch ( 17) of the facial nerve at the well side. The cross facial nerve grafts were placed orthodromically with branches lying atop the facial expression muscles, whereas the main trunks were anastomosed to the buc- cal branch of the facial nerve at the ill side. The follow up period ranged from 1 year to 20 years. Significant amount of improvements have been noticed in all patients starting from 3 months. Increase in the intensity of elevation of upper lip and mouth angle, contraction of the orbicularis oris muscle, orbicularis oculi muscle, or corrugator muscles can be observed significantly at 6 months after surgery. In those patients whose cross facial nerve grafts were anastomosed to marginal mandibular branch of the facial nerve, can obtain better lower lip balance due to simultaneous weakening of the well side lower lip depressors. In those patients whose donor nerves were the buccal branch of the facial nerve, the lower lip balance need further treatment such as depressor myectomy or injection of botulinum toxin A.

Research on Traumatic Paraplegia: Microsurgical Connection of the Above the Lesion Cord with Peripheral Nerves (C.N.S.-P.N.S. Connection) Institution where the work was prepared: Fondazione ricerca lesioni mdollo spinale, Brescia, Italy Giorgio Brunelli, professor; Fondazione ricerca midollo spinale

Our previous research started in 1980 and was done on rats and monkeys. It showed that muscles surgically disconnected from lower motoneurons respond- ed to the stimuli of upper motoneurons. Numerous groups of rats were operated on with different surgical protocols during the years. Results obtained in rats, when presented at an international meeting, at the end of the years ‘80s, stired up scepticism. Therefore during the years ‘90s four groups of monkeys were operetad on by connecting the cortico spinal tract of the above the lesion cord with the motor nerves of gluteus maximus, gluteus medius and quadriceps with good results checked by eng and histology. Recently, after having obtained the permission of the ethical committee of the national health service, three human beings have been operated on. The first one who had undergone guillotine severance of the cord by dislocation of T8 is now able to walk with tripod sticks. The other two are still to recent. Research was done on animals to see whether it is the motor end-plate which changes its receptors from cholinergic into glu- tamatergic or if it is the upper motorneuron which changes its neurotransmitter from Glutamate to Acetylcholine. A graft was put from the severed lateral or posterior white matter (rubrospinal and cortico spinal tracts) to the muscular nerve of obliquus muscle in rats. Functional reinnervation of the muscle was shown by E.M.G. and immunostaining. Genes codifying for receptors as well as the neurotransmitter were searched for. The administration of curare paralysed all the muscles but not the operated one, whereas inhibitor for glutamate paralysed the operated side. Immunoblot test showed that the operated muscle con- tains vesicular glutamate transporter-1 (VGluT-1) whereas the control muscle still contains ChAT and VAChT. Direct muscular innervation by the upper motoneuron makes the muscles function probably due to changement of the receptors of the motor end-plates under glutammatergic stimulation.

117 ASPN Scientific Paper Presentations A

A Method for Preoperative Evaluation of Brachial Plexus Birth Injuries Institution where the work was prepared: Miami Children's Hospital, Miami, FL, USA Ilker Yaylali, MD, PhD; Israel Alfonso, MD; John. A. I. Grossman, MD; Miami Childrens Hospital

Objective: To describe and report the results of a new technique to evaluate the severity of brachial plexus birth injuries.

Background: Currently, preoperative clinical examination is the only method to select candidates for early brachial plexus reconstruction surgery after birth injury. Stimulation of the cervical spinal cord activates the corresponding á-motoneurons thus producing compound muscle action potential (CMAP). This technique allows assess- ment of nerve conduction velocity and amplitude of CMAP.

Method: The spinal cord is stimulated from the surface by placing an electrode (anode) midline at the level of the 5th cervical spine apophysis; and the cathode on the lateral surface of the neck at the same level. The stimulation is performed using 100 mAmps for 0.2 ms. CMAPs were recorded from the supraspinatus, del- toid, biceps, and triceps muscles. Axonal loss was calculated by the following formula: 100 – (injured side amplitude/healthy side amplitude) X 100. Myelin loss was calculated by: 100 – (healthy side conduction velocity/ injured side conduction velocity) X 100. The average combined axonal and myelin loss was calculated by adding axonal and myelin loss from each muscle and dividing by 8.

Material: We studied 66 infants (36 female, 30 male) with brachial plexus birth injuries. Mean age at the time of evaluation was 6 months. Every infant underwent a clinical evaluation at the time of the study. Fifty patients were selected for surgery based on the clinical evaluation. All operated cases had significant nerve disruption. Results: The average combined axonal and myelin loss in patients who underwent surgery was 47.98% (sd 24.1%) and 20.18% (sd 12.3%) in patients not requiring surgery. Average combined axonal and myelin loss was significantly different between surgical and nonsurgical cases (p<0.0001). Using average combined axonal and myelin loss predicts the correct surgical decision (surgery or no surgery) in 78.8% of the cases (logistic regression).

Conclusion: We described a valuable a new technique using nerve conduction velocity and amplitude for the presurgical evaluation of infants with brachial plexus birth injuries. All patients with an average combined axonal and myelin percent loss of more than 47% had surgery; all patients with an average combined axonal and myelin loss of less than 21% did not.

Intra-operative Neurophysiologic Recordings in Obstetric Brachial Plexus Lesions Institution where the work was prepared: Leiden University Medical Center, Leiden, Netherlands Willem Pondaag, MD; J. Gert van Dijk; Martijn J.A. Malessy; Leiden University Medical Center

Introduction: A typical finding in supraclavicular exploration of infants with Obstetric Brachial Plexus Lesions (OBPLs) is a neuroma-in-continuity of the superior trunk and / or (partial) root avulsion C5, C6, C7. The intra-operative assessment of the potential for spontaneous recovery of the involved nerve elements may facilitate the surgical decision process, i.e. whether grafting or transfer is indicated. Intraoperative Nerve Action Potentials (NAP) and Compound Motor Action Potential (CMAP) recordings have been proven helpful in adults, whereas its usefulness in the intraoperative assessment of OBPLs remains to be determined.

Methods NAPs and CMAPs were systematically recorded in a consecutive series of 95 OBPL infants (mean age 175 days) surgically treated by one neurosurgeon. A total of 599 intra-operative NAPs from C5, C6 or C7 to the anterior and posterior divisions, suprascapular nerve and medial trunk were analyzed. In addition, 832 CMAPs from C5, C6 and C7 to the biceps and triceps muscles were studied. The severity of the nerve lesion of the involved elements was qualified as either axonotmetic, neurotmetic or root-avulsion by: 1/ visual inspection, 2/ induced motor response after selective electrical stimulation, 3/ CT-myelography and 4/ histopathology. The surgeon was blinded for the NAP and CMAP values. A statistical analysis was performed to assess the correlation of NAP and CMAP with the surgical diagnosis.

Results In 16% of the neurophysiologically analyzed nerve elements NAP and CMAP values could not be recorded. These recordings were assigned the value ‘zero'. NAPs and CMAPs both showed a wide numerical range, but NAPs had a larger variance than CMAPs. CMAP recordings correlated well with standard neuro- anatomical connections, while NAPs did not. CMAP and NAP values correlated with the surgical diagnosis. A decreasing voltage was found in the following order: normal > axonotmesis > neurotmesis > avulsion. Statistically significant differences were found in NAP and CMAP values between lesion types. These correlations were more distinct for CMAPs than for NAPs. In the individual patient, however, NAP and CMAP recordings could not differentiate between avul- sion, axonotmesis and neurotmesis. A clear cut-off point for CMAP and NAP data could not be found.

Conclusions Intraoperative NAP and CMAP recordings do not add to the decision-making in the nerve surgical treatment of the individual OBPL infant. The neurophysio- logical findings may reflect the nerve regenerative response which may be specifically related to the unique nature of the obstetric brachial plexus lesions.

118 Magnetic Resonance Imaging Diagnosis of Nerve Root Avulsion in Birth-Related Brachial Plexus Injury Institution where the work was prepared: Children's Healthcare of Atlanta, Atlanta, GA, USA Ann Schwentker, MD; William Boydston, MD, PhD; Denis Atkinson, MD; Children's Healthcare of Atlanta

Eighteen infants with birth-related brachial plexus injury underwent preoperative evaluation of the cervical spine using a dedicated MRI protocol with coronal, saggital and axial T1- and T2-weighted images. Thin-section axial 3D FIESTA images were obtained to delineate ventral and dorsal nerve rami. Nerve root avulsion was strongly suggested by the presence of a pseudomeningocele at the corresponding level, with or without lateralization of the dorsal root ganglion or lack of nerve root continuity. Operative reconstruction of the brachial plexus was indicated by either severe total plexus injury (Toronto score < 3.5 at 3 months of age) or nonrecovery of the biceps before 9 months (failed cookie test) in all children. At operation, the supraclavicular plexus was explored and note was made of the anatomy. Findings of an extraforaminal dorsal root ganglion or empty foramen confirmed nerve root avulsion. A structurally normal nerve root that did not stimulate the extremity at 2 mA was considered to represent an intraforaminal avulsion when this diagnosis was consistent with physical examination. The presence of extraforaminal dorsal root ganglia was confirmed with intraoperative frozen section. Sensitivity of MRI in diagnosing avulsion was 81% with a specificity of 96%. Positive predictive value was 92% and negative predictive value 91%. These results are comparable to those of CT myelo- gram, currently the gold standard for imaging in these patients. Use of a 3.0 Tesla magnet improved image quality, often allowing visualization of nerve rami and ganglia. Routine use of the 3.0 Tesla magnet would be expected to improve the validity of MRI for diagnosing nerve root avulsions in this patient popu- lation. The small patient size and low body fat content of infants complicates imaging of the extraspinal brachial plexus.

Severe Obstetric Brachial Plexus Injuries can be Identified Easily and Reliably at One Month of Age Institution where the work was prepared: Leiden University Medical Center, Leiden, Netherlands Martijn J.A. Malessy; W Pondaag; S.M Hofstede-Buitenhuis; S. le Cessie; J.G. van Dijk; Leiden University Medical Center Background Effective early management of infants with obstetric brachial plexus injury (OBPI)is undermined by an inability to assess lesion severity reliably early in life. We sought to identify predictors for a poor outcome. Methods We performed a prospective study in 48 OBPI infants with a minimal follow-up of two years. Infants were examined around one week, one month and three months of age. Thirteen dichotomous parameters were gathered each visit concerning four joint movements, skin crease asymmetry at three locations of the upper limb, and findings of needle electromyography in three muscles. The severity of the lesion was assessed by clinical examination and surgery between three and seven months of age. Surgery was performed when specified clinical patterns indicated poor prognosis. A poor outcome was defined as the presence of a neurotmesis or avulsion of spinal nerves C5 and C6 requiring nerve repair, irrespective of a C7-T1 lesion. All other outcomes were defined as good, con- forming to axonotmesis of C5 and C6 spinal nerves with good spontaneous recovery. Predictors for poor outcome were identified using a two-step hierarchi- cal forward logistic regression analysis based on likelihood-ratios. Results The mean age at visit one was 9 days (median 9, range 12), at visit two 32 days (median 31, range 29) and at visit three 87 days (median 87, range 29). Surgery was performed in 23 of 48 (48%) infants. The mean age at surgery was 143 ± 30 (median 139) days. Outcome was poor in 20 (42%) infants and good in 28 (58%). Results Prediction at one month of age was better than at one week or three months. At one month, three parameters (elbow extension, elbow flexion and motor unit potentials in the biceps muscle) correctly predicted outcome in 44/47 (93.6%) of infants, with a sensitivity of 1.0 and a specificity of 0.88. Conclusions The severity of OBPI lesions can be reliably predicted at one month of age in the majority of the infants by testing elbow extension, elbow flexion and per- forming needle elecromyography of the biceps muscle. The results can be used in routine practice to identify OBPI infants with severe lesions who may ben- efit from surgical treatment.

A 5 Year Fallow up of End to Side Vascularized Ulnar Nerve Graft for Brachial Plexus Roots Avulsion Institution where the work was prepared: Iran Medical Sciences University, Tehran, Iran Kamal S. Forootan, MD, FICS; Lida Jafari Saraf; Ahmad Maghari; Iran Medical Sciences University Introduction: Vascularized nerve graft was introduced in 1976. We suggested end to side vascularized ulnar nerve graft (VUNG) in Heidelburg in 2002. In our study, we pres- ent the outcome of our patients after 5 years. Material and methods: 13 reconstructions with end to side VUNG were operated on in our center for brachial plexus injuries from 1998 to 2001. 2 teams worked simultaneously; one in intact brachial plexus and the other harvested the ulnar nerve with its vessels in involved hand. The ulnar nerve with its vessels was raised from the wrist to about 5cm above the elbow with dividing the vessels in bifurcation and observing the bleeders in both ends of the nerve. The median, musculocutaneaus and radial nerves should be identified. One end of the nerve, which is closer to the vessels, was coaptated to posteromedial side of the upper and middle trunks through a proper subcutaneous tunnel to other side in the chest wall. The artery and vein were hooked up to any vessels. The other end was coaptated to median nerve end to end. An interposition of the nerve graft was applied between split spinal accessory and musculocutaneous nerves in involved side. 3 inter- costals nerves were raised as long as possible; and, coaptated to radial nerve directly. Results: Only 7cases could be fallowed up to 5 years. Almost all were disappointed and quite not cooperative because of long term results. The tinnel sign was fast for vascularized ulnar nerve, about 3-4 mm/day for the first 3-4 months, and then slow down. The median sensation was good but two points discrimination was disappointing. Muscle strength improvements were + for median, ++ for radial, and +++ for musculocutaneous.

Conclusion: After such studies we found that end to side VUNG should be only sacrificed for median nerve not for whole the nerve in the involved brachial plexus which we presented in Heidelburg. The more studies with more cases and fallow up for more time are suggested.

119 Metastatic Breast Cancer Recurrence to the Brachial Plexus - MRI Imaging Characteristics Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Helena Gerhardt Summers, MD; Kimberly Amrami; Robert Spinner; Mayo Clinic

Abstract: The brachial plexus is a complex and difficult structure to image, especially in patients with previous surgical and radiation treatment to nearby structures in the breast and axilla. We reviewed twenty one patients with a history of breast cancer and symptoms of brachial plexopathy, including sensory deficits, weak- ness, and pain, with MRI imaging and positive EMG findings. The majority of these patients had been “disease free” for many years (range 0-26 years, aver- age 14 years) with insidious onset of symptoms. 18 of 21 patients underwent surgical biopsy of the brachial plexus, chest wall, or supraclavicular lymph nodes. The 3 patients without surgical biopsies were treated presumptively for recurrent cancer based on imaging findings. 9 patients had PET scans. Only 9 of the 21 patients had a correct prospective diagnosis by imaging. On retrospective review the majority of cases had MRI evidence of recurrent disease including sig- nal abnormalities, abnormal enhancement, and masses. Many of the interpretations were revised after repeat examinations with intravenous gadolinium or at higher field strength (3T). This study attempts to better characterize the imaging characteristics of the brachial plexus in patients with breast cancer, with a focused goal to evaluate false positive results and, thus, eliminate unwarranted and potentially harmful surgery. By correlating imaging features with patho- logically proven cases of recurrent tumor, we also aim to accurately identify patients with breast cancer recurrence of the brachial plexus. By distinguishing true positive results from radiation fibrosis or other causes of brachial plexopathy, appropriate and earlier treatment is possible. The role of PET scanning for improv- ing sensitivity will also be evaluated.

Outcome Measures in Brachial Plexus Reconstruction Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Keith A. Bengtson; Brian Kotajarvi, PT; Allen Bishop, MD; Robert Spinner, MD; Alexander Shin, MD; Mayo Clinic

A comprehensive review of the literature on brachial plexus reconstruction reveals a paucity of detailed measures of outcome. Motor return is generally meas- ured using manual muscle testing (MMT) with the British Medical Research Council (BMRC) scale of M0-M5. Function is measured in descriptive and fairly insensitive terms. The insensitivity of the BMRC scale is greatest at the upper and lower extremes between M0 and M2, as well as between M4 and M5. MMT, especially when performed by various examiners from several medical centers, results in a high variability of measures. Higher variability requires larger num- ber of patient to prove efficacy of treatment.

One way to reduce variability is to use isometric motor testing with force plate gauges which are highly sensitive to small variations in strength. Various iso- metric strength testing devices already exist for the shoulder and elbow motions. Unfortunately, these machines do not eliminate the effect of gravity. Therefore, early recovery, when the muscle is not strong enough to overcome gravity, is not detected. Our group has developed specific, reproducible testing of muscle strength using standardized placement of force plates in such a way as to eliminate the effects of gravity. These techniques measure the isometric force gen- erated by a muscle group in a standardized fashion. Specifically, force is measured in shoulder flexion, extension, abduction, internal rotation, and external rotation. Elbow flexion and extension, and forearm pronation is also measured. We hope to establish standards of measurement that will aid in future research on the success of brachial plexus reconstruction. These protocols will be described as they pertain to specific types of brachial plexus reconstruction. We will also present preliminary results from illustrative cases.

A Long Segmental Nerve Trunk Crush Injury Induces Increased Sprouting but does not Impair Peripheral Nerve Regeneration Institution where the work was prepared: University of Calgary, Calgary, Canada Qing Gui Xu; Rajiv Midha, MD; Douglas Zochodne; University of Calgary

Background: Nerve crush is a well established rodent model of a Sunderland Grade II nerve injury. We hypothesized that a long segmental peripheral nerve trunk crush injury would impede axonal regeneration as compared to a short focal crush injury.

Methods: In Sprague–Dawley rats (n=8-10/group), the mid-thigh sciatic nerve was exposed and then crushed for 30 seconds, using either a plastic-tipped jewelers for- ceps (crush zone 2 mm) or a modified snap, lined with smooth 2 cm long reciprocal plastic resin cassettes, which upon closing caused a long zone (20mm) crush injury. Two weeks following injury, nerve samples were harvested 5 and 15mm distal to the proximal injury level. Toluidine blue stained semithin sec- tions were evaluated by an observer blinded to treatment groups for myelinated axon counts. Semi-quantitative RT-PCR for a number of expressed genes, including GAP-43/B50, was also performed on the injured nerve. In another set of rats (3/group), retrogradely labelled (using flurogold) neurons were count- ed from the lumbar spinal cord and L5 DRG.

Results: Both short and long crush produced regenerative sprouting, with myelinated axon densities significantly (p<0.01) greater in the proximal as compared to dis- tal sampling sites. The long crush injury had 50% greater myelinated axon density 5 mm distal to injury (density of axons long vs. short p=0.05). Despite the initially greater sprouting within the longer crush zone, axon counts 15mm distal were identical between the 2 groups. GAP 43/B50 expression was signifi- cantly up-regulated in the longer crush group. There was no significant difference in the number of labeled motor neurons in spinal cord and sensory neu- rons in DRG in the 2 groups, indicating identical regeneration success.

Conclusions: While a longer crush segment results in significantly increased sprouting, regeneration over a greater distance is similar to the short, focal crush injury. We con- clude that the regenerating peripheral nerve demonstrates remarkable fidelity in reinnervation potential, even at early time-points, despite considerable differ- ences in the local crush lesion size.

120 Alteration in Signaling Programs Demonstrated by Migrating Schwann Cells Institution where the work was prepared: Washington University in St. Louis, St. Louis, MO, USA Ayato Hayashi, MD; Terence M. Myckatyn, MD; Alice Y. Tong, MS; Daniel A. Hunter, RA; Daniel Z. Liu, BA; Jason W. Koob, BA; Arash Moradzadeh, MD; Jamie D. Gaertner; Thomas H. Tung, MD; Susan E. Mackinnon, MD; Washington University School of Medicine

Background: Antigenic tissue in a peripheral nerve allograft is eventually replaced by regenerating host axons and Schwann cells to preclude the need for indefinite immuno- suppression. Schwann cell migration into peripheral nerve allografts is poorly characterized in terms of Schwann cell phenotype at various stages after nerve grafting, and the associated intracellular signaling pathways.

Method: To study the rate of Schwann cell migration and the alteration of Schwann cell signaling in a nerve allograft, we used S100-GFP mice, whose Schwann cells constitutively express green fluorescent protein (GFP), as recipients and performed an allograft from non-fluorescent donor mice. The animals were random- ized into four treatment groups. In one group, the nerve allograft was transplanted without any additional treatment. In another, the donor nerves were cold preserved 7 weeks to eliminate any viable cells or antigenicity. In another, mice were treated with FK 506 to eliminate the direct pathway of nerve allograft rejection. In the last group, mice were treated with anti-CD40 and CTLA4-Ig to block the costimulatory pathway of nerve allograft rejection. 5 days and 28 days after the surgery, allografts were harvested to characterize Schwann cell migration using histomorphometry, immunohistochemistry, and western blot analysis. We focused on the MAPK-Erk signaling pathway to investigate Schwann cell dedifferentiation to proliferating phenotypes, the phospho-Akt signal- ing pathways to identify mature, myelinating Schwann cells, and the caspase-3 mediated cell death pathway. Histomorphometry with electron microscopy fur- ther characterized the structure of regenerated axons and Schwann cells. Western blot analysis of other signaling proteins relevant to Schwann cell viability and differentiation were also performed.

Results: Untreated allografts are characterized by significant host Schwann cell migration, and proliferating cells are observed throughout the graft. Western Blot analy- sis also shows high level of Caspase-3 expression. Cold preserved allografts provide the most powerful stimulus for Schwann cell migration, while costimula- tory blockade preserved donor Schwann cells and minimized migration. Mice treated with Fk506 had increased level of caspase-3 expression than those treat- ed with anti-CD40L mAb and CTLA4-Ig.

Conclusion: From these results, we suspect that a nerve allograft, devoid of Schwann cells, will induce dedifferentiation and migration of host Schwann cells into the graft. This study provides further insights at an intracellular level into the characteristics of migrating adult Schwann cells, and alteration in signaling programs at multiple time points.

Atraumatic Electrophysiologic Evaluation of Nerve Regeneration Following Nerve Injuries of the Forelimb in Rats Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Huan Wang, MD, PhD; Eric J. Sorenson, MD; Anthony J. Windebank, MD; Robert J. Spinner, MD; Mayo Clinic

Introduction: The aim of the study is to develop electrophysiologic testing of nerve injury and recovery without having to expose nerve repair site, and evaluate validity of the method.

Methods: 18 adult female Sprague Dawley rats were randomly divided into 3 groups, with 6 each. The median nerve, ulnar nerve, or both median and ulnar nerves were transected at elbow and immediately repaired by direct coaptation in group A, B, C respectively. In group A, compound muscle action potential (CMAP) for evaluation of median nerve motor recovery was recorded by placing subcutaneous needle electrode at the thenar muscle while the median nerve was transcu- taneously stimulated at the cubital fossa. In group B, CMAP for evaluation of ulnar nerve motor recovery was recorded by placing subcutaneous needle elec- trode at the hypothenar muscle while the ulnar nerve was transcutaneously stimulated proximal to the cubital tunnel. In group C, CMAP recording for both median and ulnar nerves was conducted. Sensory recovery was evaluated by cortical recording of somatosensory evoked potential (SEP) while delivering stim- ulation to the 2nd digit for the median nerve and the 5th digit for the ulnar nerve with cathode and anode clamped to the digit. These measurements were conducted preoperatively and 1, 3, 4, 6, 8, 10, 12, and 16 weeks postoperatively.

Results: In group A, latency, duration, amplitude and area of preoperative CMAP were 1.47±0.27 ms, 1.35±0.23 ms, 6.97±2.35 mV and 3.58±1.33 mVms respectively. One and 3 weeks postoperatively no CMAP was recorded. From the 4th week CMAP came back with latency, duration, amplitude and area being 9.43±2.95 ms, 9.38±4.01 ms, 0.09±0.02 mV and 0.53±0.20 mVms respectively. As postoperative interval increased, CMAP latency and duration shortened and its ampli- tude and area increased. Those parameters, except for latency, returned to preoperative level in 12 weeks. SEP of the median nerve was recorded preoperative- ly with initial latency, peak latency and amplitude being 12.78±1.68 ms, 18.38±1.85 ms, and 38.94±31.55 mV respectively. One week postoperatively SEP was not recordable. SEP was present in all animals 3 weeks postoperatively with no difference in initial latency and peak latency. The latency did not change with time while SEP amplitude fluctuated. In group B and C, similar findings were observed.

Conclusion: It is possible to conduct atraumatic electrophysiologic test in rat upper limb. CMAP is a valid parameter that shows typical time course of nerve regeneration and reinnervation. SEP is less sensitive and quantitative.

121 Development of Assessment Tasks for Evaluating Deficits and Recovery of Forelimb Function following Nerve Lesions in Rats Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Huan Wang, MD, PhD1; Eric J. Sorenson, MD1; John P. Bois, BA2; Godard C.W. De Ruiter, MD1; Anthony J. Windebank, MD1; Robert J. Spinner, MD1; (1)Mayo Clinic, (2)Mayo Medical School

Introduction: Despite the fact that the incidence of nerve injuries of the upper limb is much higher than that of the lower limb, most experimental studies of peripheral nerve injury have been using rat sciatic nerve as the research model. This model is not void of disadvantages such as autotomy and joint contracture that will hinder functional assessment. The aim of the current study is to develop an evaluation task for upper limb nerve injury models in the rats.

Methods: Various upper limb nerve injury and repair models were created in 40 Sprague Dawley rats. The median nerve, ulnar nerve, radial nerve, and combined medi- an and ulnar nerve transection and direct coaptation were done proximal to the elbow. Rats without surgery and with sham operation served as control. Atraumatic electrophysiological tests were developed to record compound muscle action potential (CMAP) and somatosensory evoked potential (SEP). Impairment and recovery of muscle power were measured by grip strength. Gait cycle was analyzed by applying motion analysis to reveal movement of the wrist and metacarpophalangeal (MP) joint and the changes of toe spread. All those measurements were conducted preoperatively and 1, 3, 4, 6, 8 10, 12 and 16 weeks postoperatively.

Results: Compound muscle action potential was a valid parameter that showed typical time course of nerve regeneration and reinnervation. Grip strength was not impaired by radial nerve injury. Median or ulnar nerve injuries led to reduced grip strength, the most dramatic change being seen in combined median and ulnar nerve injury which didn't recover to normal until 12 weeks postoperatively. Grip power returned to normal 6 weeks postoperatively for ulnar nerve injury only model and 12 weeks for median nerve injury only model. Motion analysis could quantify the decrease in wrist and MP joint extension following radial nerve injury, the decrease of wrist and MP joint flexion following combined median and ulnar nerve injury or median nerve only injury. No obvious change of joint movement was seen in ulnar nerve only injury. Obvious decrease of toe spread was observed in combined median and ulnar nerve injury model and radi- al nerve injury model. Median nerve only or ulnar nerve only injury did not lead to significant change in toe spread.

Conclusion: Nerve injuries of the upper limb in rats can be evaluated combining electrophysiology, behavioral test, and motion analysis.

Embryonic Stem Cell Derived Motor Neurons Form Neuromuscular Junctions In Vitro and Enhance Motor Functional Recovery In Vivo Institution where the work was prepared: Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA Tateki Kubo, MD, PhD; Mark Randolph, MAS; Jonathan M. Winograd, MD; Massachusetts General Hospital, Harvard Medical School

INTRODUCTION: Proximal peripheral nerve injuries, such as brachial plexus palsies, whether obstetrical or traumatic, are devastating injuries with significant impairment of the affected limb, resulting in functional paralysis, sensory deficits. Because of the prolonged delay in nerve regeneration, chronic muscle atrophy and fibrosis con- tinues to be a severe, irreversible impediment to recovery. We hypothesize that transplantation of embryonic stem (ES) cell derived motor neurons may enhance outcomes by better supporting the biological integrity of the injured muscle and nerve. These motor neurons may provide trophic support to the muscle by forming neo-neuromuscular junctions and up-regulating specific growth factors, preserving motor unit integrity. In the current study, we examine the func- tional properties of ES cell derived motor neurons in vitro, and the effect of this transplant in vivo on the functional outcome after nerve repair.

METHODS: In Vitro Experiment: Murine GFP/HB9 ES cells are differentiated into motor neurons using Retinoic Acid and Sonic Hedgehog for four days. C2C12 skeletal myocytes are plated in laminin coated dishes and differentiated to form myotubes. After formation of myotubes, co-cultures are prepared with motor neu- rons. The formation of neuromuscular junctions is confirmed with synaptic markers using immunocytochemistry on the myotubes. In Vivo Experiment: Tibial nerve transaction is performed without nerve repair, and motor neurons are transplanted into the nude mouse gastrocnemius muscle. Quantitative and histo- logical assessments of gastrocnemius muscle are done at days 7 and 21. Additional experimental groups, in which the tibial nerve underwent repair after trans- plantation, were also performed. The effect of the transplants on functional recovery following nerve repair is investigated with walking track analysis in those groups.

RESULTS: In Vitro Experiment: GFP/HB9 ES cells were differentiated into GFP+ fluorescent motor neurons. Co-cultures of motor neurons and myotubes formed neu- romuscular junctions, confirmed by the presynaptic markers, VAMP-2 and VAChT antibodies, and postsynaptic marker, a-bungarotoxin. In Vivo Experiment: In the experiment of tibial nerve transaction without nerve repair, the gastrocnemius muscle injected with motor neurons were less atrophied than control PBS injected muscle at both days 7 and 21. The functional recovery after nerve repair with motor neuron transplantation was evaluated with walking track analy- sis. It was significantly enhanced compared to PBS injected group.

CONCLUSION: The present study confirmed the formation of neuromuscular junctions using ES cells differentiated into motor neurons in vitro. Transplantation of motor neurons prevented muscle atrophy following denervation. Following tibial nerve repair, motor neuron transplantation improved motor functional recovery.

122 Accuracy of Motor Axon Regeneration After Different Types of Nerve Injury and Repair in the Rat Sciatic Nerve Model Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Godard C.W. De Ruiter, MD1; M.J.A. Malessy2; Robert J. Spinner, MD1; A.O. Alaid1; J.K. Engelstad1; E.J. Sorenson, MD1; K.R. Kaufman, PhD1; P.J. Dyck, MD1; A.J. Windebank, MD1; (1)Mayo Clinic, (2)Leiden University Medical Center BACKGROUND: Misrouting of regenerating axons is one of the factors that may explain the poor results often found after nerve injury and repair. Different techniques have been used to investigate the accuracy of regeneration, but little is known about the degree of misrouting, especially in the repair of motor nerves that inner- vate different target muscles. MATERIALS: We investigated the accuracy of motor axon regeneration in the rat sciatic nerve model after crush injury, direct coaptation, and autograft repair using two recently introduced evaluation techniques: sequential retrograde tracing and digital video ankle motion analysis. Sequential tracing with retrograde labeling of the peroneal motoneuron pool before and 8 weeks after nerve injury and repair was performed to quantify the accuracy of motor axon regeneration. Ankle motion was analyzed to investigate the impact of misrouting on the recovery of ankle plantar and dorsiflexion. In addition, quantitative results of regenera- tion were determined from compound muscle action potential recordings every other week, as well as nerve and muscle morphometry. RESULTS: After sequential tracing, only 71.4% (± 4.9%) of the peroneal motoneurons were found to be correctly routed 8 weeks after sciatic crush injury, 42.0% (± 4.2%) after direct coaptation repair, and 25.1% (± 6.6%) after autograft repair. Functional recovery after all types of nerve injury and repair function was incomplete partly as a result of a disturbed balance of ankle plantar and dorsiflexion. Quantitative results showed that reinnervation was faster after sciatic crush injury than after direct coaptation and autograft repair. The mean muscle fiber size was also larger after crush injury. The number of regenerated motoneurons after all types of nerve injury and repair was not significantly different from normal, but the number of myelinated axons was significantly increased distal to the site of injury. CONCLUSION: Accuracy of regeneration after different types of nerve injury and repair in this study was found to be limited. These results can be used as basis for the devel- opment of new nerve repair techniques that may improve the accuracy of regeneration.

Reconstruction of a 40 mm Nerve Gap in Rats Using Biodegradable Nerve Conduits Filled with Schwann Cells Institution where the work was prepared: University of Tuebingen, Department of Handsurgery, Tuebingen/Germany, Germany nektarios Sinis, MD1; Max Haerle, MD1; Stefan Becker, MD1; Burkhard Schlosshauer, PhD1; Michael Doser, PhD2; Harald Roesner, PhD3; Klaus Dietz, MD1; Hans-Werner Mueller, PhD4; Hans-Eberhard Schaller, MD1; (1)University of Tuebingen, (2)ITV-Denkendorf, (3)University of Hohenheim, (4)University of Duesseldorf

In a former study we used a biodegradable nerve conduit consisting of a trimethylenecarbonate-co-epsilon-caprolactone (TMC/CL) polymer seeded with Schwann cells to induce and promote regeneration across a 20 mm nerve gap in the rat median nerve. Regeneration was estimated to be equal to that of an autologous graft, as judged by functional, histological, and electrophysiological parameters, as well as by muscle weight analysis of the flexor digitorum sub- limis muscle. In this study we increased the gap distance to 40 mm using a cross-chest procedure with interposition of the Schwann cell-filled nerve conduits from the left median nerve to the right (group 3; n=16). For the autologous graft subjects, both ulnar nerves were harvested and interposed between the medi- an nerve stumps to create a 40 mm long autograft (group 2; n=16). A further control group was created using 16 non-operated animals (group 1). The func- tional regeneration was assessed by means of the grasping test. Further examination was performed with histological analysis (S-100, PAM, Nissl), electrophys- iological recordings, and weighing of the flexor digitorum sublimis muscle. After 12 postoperative months, functional regeneration was seen only in three ani- mals of group 3 which reached about 10 % of that of the non-operated control animals (group I), however all autologous grafted animals demonstrated a par- tial functional regeneration. Histological analysis of sections collected from these animals with the bioartificial nerve conduit confirmed strong morphological changes with signs of Wallerian degeneration. In animals supplied with an autologous graft the histology demonstrated a more organized architecture of axons. Electrophysiological recordings in the nerve tube supplied animals were displayed only in those three animals that demonstrated regeneration, while all animals in the autologous graft group exhibited regenerative potentials. Furthermore, there was a significant decrease of muscle weight in the nerve conduit supplied animals, which was more prominent than in the autologous grafted group. These results draw attention to the complexity of the mechanisms involved in nerve regeneration since the bioartificial nerve conduit was successfully applied in a 20 mm gap however demonstrated only minor success in experiments 12 months post surgery across the double gap length of 40 mm. Further consideration should be taken in optimizing the cellular and material components critical for successful application. Schwann cells, nerve conduit, nerve regeneration, cross-chest procedure

Biodegradability of Synthetic Nerve Grafts Is Beneficial to Peripheral Nerve Regeneration Institution where the work was prepared: Leiden University Medical Centre, Department of Neurosurgery, Leiden, Netherlands Carmen L.A.M. Vleggeert-Lankamp, Drs1; J.F.C. Wolfs1; Ana P. Pego, Drs2; R.J. van den Berg1; H.K.P. Feirabend1; Martijn J.A. Malessy1; E.A.J.F. Lakke1; (1)Leiden University Medical Center, (2)University of Twente

In the present study we consider the influence of biodegradability of the synthetic nerve graft on regeneration. TriMethylene Carbonate (TMC) was copolymer- ized with poly-Â-caprolactone (CL) to create a faster degrading copolymer. Nerve guides with an outer layer of TMC/CL and an inner layer of either TMC/CL (fast degradable graft) or TMC (slowly degradable graft) were compared to each other, and to autografts and unoperated nerves. Twelve weeks after bridging a 6 mm sciatic nerve lesion in the rat, the integrity of the nerve guides, the morphology of nerve at midgraft, morphometrical parameters of nerve and inner- vated muscle, and electrophysiological parameters of the nerve were evaluated. The observed changes in nerve fibre morphology were used to calculate pre- dicted values of the electrophysiological parameters. We attribute differences between measured and predicted electrophysiological parameter values to com- pensatory changes of the axonal ion channel composition. This study shows that the fast degradable graft disintegrated and that the slowly degradable graft remained partially intact. The values of the morphometrical parameters of the peroneal nerves and the gastrocnemic and tibial muscles were similar if not equal in the synthetic nerve grafted rats, while some of the electrophysiological parameters were different. The refractory period in the fast degradable nerve grafts was equal to unoperated nerves, while it lenghtened in slowly degradable nerve grafts. In both slow and fast degradable nerve grafts the conducted charge diminished, and in slowly degradable grafts the charge even fell below the expected value. Based on these data it can be concluded that fast degradable grafts are better than slowly degradable grafts, though the observed differences are small.

123 ASPN Scientific Paper Presenations B

Pressure Changes in the Medial Plantar, Lateral Plantar, and Tarsal Tunnels Related to Ankle Position: A Cadaver Study Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA Gedge D. Rosson, MD; Allison R. Barker; A. Lee Dellon; Johns Hopkins University School of Medicine

Background: Pressure in the tarsal tunnel has been shown to be elevated in pronation. We hypothesized that this result would hold for the medial plantar and lateral plan- tar tunnels since they are also potential sites of nerve compression. Additionally we hypothesized that decompression surgery, including a release of the super- ficial and deep fascia of the abductor hallucis brevis muscle and excision of the septum between the medial and lateral plantar tunnels, would decrease the pressure in all three tunnels.

Methods: Twelve fresh cadaver legs were obtained and pressure measurements were made in the tarsal, medial and lateral plantar tunnels before and after decompres- sion surgery in a variety of foot positions. For the medial and lateral plantar tunnels, pressures were obtained after tunnel roof (deep fascia of the abductor hallucis) incision and after both roof incision and excision of the septum between the two tunnels.

Results: Our results show significantly elevated pressures in all tunnels in pronation, significantly decreased pressures in all positions in the tarsal tunnel with decom- pression, and significantly decreased pressure in most positions in the medial and lateral plantar tunnels with decompression. Septum excision led to addition- al significant decreases in pressure in some positions.

Conclusions: Pressure within the medial and lateral plantar tunnels as well as the tarsal tunnel increase significantly with changes in ankle subtalar position. These pressure changes can be significantly decreased by surgical release of each of these three tunnels, including excision of the septum between the medial and lateral plan- tar tunnels.

Clinical Relevance: Symptoms related to chronic compression of the tibial nerve and its branches at the ankle/foot level may be relieved by a surgical strategy that targets release of multiple anatomic regions of tightness in the medial ankle rather than focusing upon the tarsal tunnel alone.

124 TEM Chracteristic of Vibration Injury in Peripheral Nerves Institution where the work was prepared: Medical College of Wisconsin, Milwaukee, WI, USA ji-Geng Yan, MD; Hani S. Matloub; Lin-Ling Zhang; James R. Sanger; Danny A. Riley, PhD; Medical College of Wisconsin

INTRODUCTION: This study was to determine pathological feature of vibration injury to the peripheral nerves.

MATERIALS AND METHODS 24 male Sprague-Dawley rats were randomly divided into two groups: sham control and vibrated. Customized Vibrating Platform: A smaller vibrating platform(frequency 43.5 Hz, amplitude 1.5mm); A larger no-vibrating platform. Methods: Rats were anesthetized and their hind limbs fixed to the vibrating platform by Velcro loops. The remainder of the body rests on the no-vibrating platform. The rats were vibrated 4 hours/day, for 7 days. At the end day sciat- ic nerves from both groups were harvested after perfusion using glutaraldehyde. Neural Fixation: The aorta was cannulated and perfused. The tissue was sub- jected to post fixation by placing it in a buffered solution of osmium tetroxide with a 1.5% concentration of potassium ferricyanide added to the buffered osmic acid mixture. Then the neural tissue was submitted for light and electron microscopy.

RESULTS: While light microscopy showed minimal histologic differences between vibrated and control nerves, the changes revealed by electron microscopy were dramat- ic. After 2 days-vibration these included thickening of the epineurium, thickening of the myelin sheath ruptured gap between the mylins, and many vacuoles were seen in the plasma. These changes were found in all vibrated animals. After 7 days-vibration myelin balls, consisting of destroyed myelin rolled into wool- like threads, were located inside the myelin layers. Axonal damage was seen in both myelinated and nonmyelinated axons.In addition, nonmyelinated axons were edematous. An interesting finding was the circumferential disruption of several myelin layers, leaving a large circular space around the impacted myelin with central axonal constriction. This chracteristic finding, giving the appearance of a finger ring, was found in every vibrated nerve. Many microtubes and microfilaments were ruptured or had disappeared.

DISCUSSION Compared to control nerves, the vibrated nerves show definite pathologic changes in the form of axonal damage and myelin fragmentation Furthermore, axon- al damage is seen in both myelinated and nonmyelinated axons. We therefore conclude: 1) Myelin disruption, myelin balls, myelin “finger ring” changes, and axonal vacuoles are identifiable characteristics of the neuropathological changes due to vibration injury. 2) The neuropathological changes probably occur in the following sequence. First the myelin sustains impacting force by vibration and becomes thick; next, there is partial rupture of the myelin; third, myelin balls or “finger rings” form; finally, constriction impedes, then destroys axoplasma. Further research to identify the hazardous components of vibration (amplitude, frequency, etc.)

Peripheral Nerve Injury after Hallux Abducto Valgus Surgery Institution where the work was prepared: Ankle and Foot Institute of Arizona, Tucson, AZ, USA Jerome K. Steck, DPM; Ankle and Foot Institute of Arizona

Hallux valgus (bunion) surgery is very common, According to the National Health Interview survey conducted by the National Center for Health Statistics; this condition affects 1% of adults in the United States. Gould et al found that the incidence increased with age, with rates of 3% in persons aged 15-30 years, 9% in persons aged 31-60 years, and 16% in those older than 60 years.

Gould et al also reported a higher incidence in females versus males, with ratio of 4:1. Approximately 10%-20% of patients with bunions eventually have them surgically treated. Of these, 10% have a complication almost half of which are related to peripheral nerve damage.

From November 2003 through May 2006 twenty-four patients with peripheral nerve damage after bunion surgery were treated surgically for severe pain after failure of conservative care. There were twenty females and four males. All patients had exploration of the peripheral nerve most likely producing their symp- toms and in our series included the deep peroneal, superficial peroneal, medial plantar, and their branches.

Nineteen patients (79%) had a peripheral nerve entrapped in scar tissue. The etiology of the remaining 6 (21%) included irritation of hardware 2 (8%), stump neuroma from transected nerve at initial procedure 2 (8%), and undetermined 2 (8%).

Fifteen patients (63%) had a successful outcome with exploration and decompression of the affected nerve, the remaining 9 patients (37%) required a dener- vation due to irreparable damage to the nerve. Twenty one patients (88%) rated their results as excellent and the remaining 3 patients (12%) were fair. Five patients had a second surgery (denervation) after an attempt at decompression.

Complications after hallux valgus surgery are common. Many foot and ankle surgeons overlook peripheral nerve damage as a possible etiology of these com- plications. This paper looks at the surgical treatment of twenty-four of these complex patients with promising results.

125 The Diagnostic Value of Ultrasound in Cubital Tunnel Syndrome Institution where the work was prepared: Wake Forest University School of Medicine, Winston-Salem, NC, USA G.D. Chloros, MD; Ethan R. Wiesler; Michael S. Cartwright; Hae W. Shin; Francis O. Walker; Wake Forest University School of Medicine

Purpose: Cubital Tunnel Syndrome (CuTS) is traditionally evaluated by a thorough history, physical examination and nerve conduction studies. However, it encompass- es a spectrum of clinical findings making its diagnosis difficult or even impossible solely on clinical grounds and/or NCS. The purpose of this study is to doc- ument the ultrasonographic measurement differences in ulnar nerve size between patients with UNE and controls and to correlate these findings with clinical examination findings and NCS abnormalities, thereby testing the validity of ultrasound (US) as an additional diagnostic modality for CuTS.

Methods: Twelve elbows in 12 patients (6 males and 6 females, mean age = 51 years, range, 16 - 68) with symptoms, clinical examination and NCS findings consistent with CuTS underwent US of the ulnar nerve at the elbow. Patients were excluded if they had history of polyneuropathy, acute trauma involving the upper extremity, any kind of trauma in the region of the elbow (including previous surgery), or brachial plexus injury. The control group consisted of 60 elbows of 30 normal volunteers (19 females, 11 males, mean age = 30 years, range 24 - 50) that also underwent ultrasound. Maximal cross-sectional areas (CSA) were measured and compared for the two groups and correlation analysis was performed between nerve size and NCS findings.

Results: The average CSA of the ulnar nerve was 6.5 mm2 (range: 5.0 to 10.0, SD = 0.09) in the control group, whereas in the CuTS group was 17.0 mm2 (range: 12.0 to 37.0, SD = 8.0), p<0.001, indicating a significant statistical difference in ulnar nerve size between the two groups. The Pearson correlation coefficient between motor NCS velocity and the US CSA was 0.80 (p=0.0019) and between the percentage of slowing of the motor velocity across the elbow and US CSA was 0.60 (p= 0.0403), suggesting that higher values of US CSA are associated with slowing of the motor velocity.

Conclusions: High-resolution US is a non-invasive, safe and reliable modality for imaging the ulnar nerve at the elbow in patients with CuTS and may provide a valuable adjunct to the NCS in the diagnosis of that disorder.

Ballistic Injuries of Peripheral Nerves: Imaging Aspects Institution where the work was prepared: Tel Aviv Sourasky Medical Center, Tel Aviv, Israel Moshe Graif, MD; Shimon Rochkind, MD; Tel Aviv Sourasky Medical Center Purpose: To analyze the sonographic features of the peripheral nerves injuries caused by gun shot wounds (GSW) and shrapnel in order to assess the impact of the sono- graphic findings on the surgical decision taking process.

Methods: Preoperative US examinations of the soft tissues were performed in 49 patients suffering from ballistic injuries (29 GSW and 20 shrapnel or munitions frag- ments). US examinations were performed with standard US units equipped with color Doppler capabilities using a variety of linear and curvilinear transducers (frequency band: 10-5MHz, 12-5MHz, and 13-5 MHz). Features such as nerve continuity, nerve texture and focal changes were evaluated as well as their rela- tion to the adjacent anatomical structures.

Results: A variety of sonographic findings were detected either intraneural in location (full or partial discontinuity, nerve retraction, texture changes) or in the area adja- cent to the nerve (hematoma, scar tissue, granulation tissue, foreign bodies, vascular lesions).

Conclusions: Imaging modalities commonly used for musculoskeletal assessment such MRI and CT may have serious limitations in the presence of metal objects within the scanning field of interest. Ultrasound appears to have logistical advantages in this respect being able to provide subtle and exquisite details of nerve anatomy and traumatic pathology and early assessment of the nerve condition. Exact location of the lesion in respect to the penetration wound site, type and size of the lesion and its relation to the surrounding tissues are all valuable data in the surgical decision taking process.

126 Treatment of Painful Neuroma by End-to-End Neurorraphy and a Nerve Conduit Institution where the work was prepared: Georgetown University Hospital, Washington, DC, USA Ivica Ducic, MD, PhD; Ali Al-Attar, MD; Georgetown University Hospital

There are number of reported treatments for painful neuroma. Most commonly, following the neuroma excision they include implantation of the proximal nerve stump into muscle or bone. About sixty year ago, attempts were made with the end-to-end neurorraphy as an alternative solution for neuroma treatment but failed to prove the efficacy. Over the past few years, five patients with forehead or dorsum of the foot neuroma, allowed us to re-visit the effectiveness of the end- to-end neurorraphy. Five consecutive patients presented with forehead (3 patients) and dorsum of the foot (2 patients) pain. The first three patients had traumat- ic (2) or post-operative (1) supraorbital/supratrochelar nerve neuroma, while the remaining two patients had post-operative superficial and/or deep peroneal nerve neuroma. The conservative managements provided no pain relief. Patients had pain for 2.3 years (1.9-4 y) in average. Patients with forehead headaches refused trigeminal ablative procedures, while patients with dorsum of foot neuroma desired no proximal nerve excision in order to maximally preserve the sensation. Therefore, following neuroma excision, the terminal end of supraorbital nerve was sutured into the terminal end of supratrochelar nerve via a nerve conduit. Similarly, neuroma of the superficial peroneal nerve (1 patient) and superficial/deep peroneal nerve (1 patient) were addressed in patients with foot pain. Patient's follow up was 2.1 year (range 1.5-2.9 years). Pre-operative pain level was 6-7 without direct stimulation of the neuroma, while with the pressure over the painful site was 10. Post-operatively, after the resolution of the incisional pain, the resting pain was 0-1, while when the direct pressure was applied over the neurorraphy site, it was 3-4 for few weeks and 1 at 1 year (p<0.001). By 6 moths post-op, no Tinel sign in patients with foot pain was any more present. All three patients with forehead neuralgia had no more headaches. All five patients reported improvement in quality of life. This highly selected group of patients with chronic post- operative/traumatic neuroma in difficult anatomical areas can successfully be treated with end-to-end neurorraphy. We believe that the success we have compared to unsuccessful end-to-end neurorraphy attempts in mid 40-s is in the use of the nerve conduit that directs the nerve axons towards each other, rather then allow- ing them to sprout into the subcutaneous tissues and thus reform a neuroma. Histological and immunohistochemical animal studies are underway and should be available for presentation documenting the lack of reformation of neuroma with applied technique.

Ballistic Injuries of Peripheral Nerves: Clinical Aspects Institution where the work was prepared: Tel Aviv Sourasky Medical Center, Tel Aviv, Israel Shimon Rochkind, MD; Tzvi Shlitner, MD; Malvina Alon, MD; Nachum Chudnovsky, MD; Moshe Graif, MD; Tel-Aviv Medical Center, Tel-Aviv University

Purpose: An overview of our experience surgically treating peripheral nerve ballistic injuries (GSW or shrapnel) analyzes the mechanism of injury, importance of the tim- ing of surgical intervention, intraoperative findings and its effects on prognostic factors common and dissimilar in these two types of injuries.

Methods: Pre- and postoperative clinical and electrophysiological evaluations of 2 groups of patients (46 GSW and 36 shrapnel injuries) were analyzed. The follow up period after the operation ranged from 1 to 5 years.

Results: The presented clinical syndrome in most cases consisted of pain and sensoromotor deficiency in the distribution of the involved nerve. The preoperative EMG evaluation supports clinical findings. Ultrasound evaluation of the nerve detected foreign body, tissue swelling, scar and neuroma formations. In most GSW cases the intraoperative findings revealed that the place of the bullet tract, the affected nerve area or posttraumatic neuroma were well differentiated by clear anatomy of the proximal and distal parts of the nerve. In most shrapnel injury cases the affected area was widespread and an intraneural foreign fragment, interfascicular hardened scar tissue or small interfascicular neuromas were found. Both groups showed motor and electrophysiological improvement after micro- surgical treatment, however the long term neuropathic pain was significantly more expressed in the shrapnel injury group.

Conclusion: This study suggests that shrapnel injury is more destructive for nerve tissue than gun shot injury. Our impression is that early surgical intervention in shrapnel injuries (especially when small fragments are recognized in the nerve) decreases postoperative neuropathic pain.

127 The Cystic Transverse Limb of the Articular Branch: A Pathognomonic Sign for Peroneal Intraneural Ganglion Cysts at the Superior Tibiofibular Joint Institution where the work was prepared: Mayo Clinic, Rochester, MN, USA Nicholas M. Desy, BSc1; Kimberly K. Amrami, MD2; Robert J. Spinner, MD2; (1)McGill University School of Medicine, (2)Mayo Clinic

Introduction: The preoperative diagnosis of peroneal intraneural ganglion cysts is difficult to establish and superior tibiofibular joint connections may not be identified. Misdiagnosis leads to incomplete treatment; the articular branch connection may not be addressed which can result in cyst recurrences. We hypothesize that knowledge of anatomy of the reproducible u-shaped articular branch and its pathoanatomy in cases of intraneural ganglion cysts can be exploited to allow successful diagnosis of these cysts.

Materials and Methods: Twenty surgically confirmed cases of paraarticular cysts (twelve peroneal intraneural ganglia and eight extraneural ganglion cysts) arising from the superior tibiofibular joint were analyzed to determine common MRI characteristics in intraneural ganglion cysts that would allow distinction from extraneural ganglion cysts. We identified and tested 3 simple radiographic signs describing the cysts and analyzed cyst morphology, muscle compartments and neighboring joints.

Results: Retrospective review confirmed that these cysts were frequently misdiagnosed and joint connections were often not recognized. The MR appearance of per- oneal peroneal intraneural ganglion cysts was stereotypic; they were tubular whereas the extraneural were globular. The “tail sign” was 100% sensitive for iden- tifying joint connections but could not distinguish between intra and extraneural ganglion cysts. The “transverse limb” sign [cystic material within the articu- lar branch traversing the anterior fibula] was present in all cases of intraneural ganglia and none of the extraneural ganglia. The “signet ring” sign [the eccen- tric displacement of fascicles by intraepineurial cyst] was 100% sensitive for intraneural ganglion cysts and 86% specific (it did not identify 2 cysts that did not extend more proximally into the common peroneal nerve). There was 100% interobserver concordance between the prospective interpretations by a blind- ed radiologist and a trained first year medical student with intraoperative findings. Muscle denervation was more common in the intraneural than extraneural ganglion cysts. Abnormalities in neighboring joints were noted nearly universally.

Conclusion: This paper demonstrates reproducible MRI features which facilitate the identification of the joint connection (“tail” sign) in para-articular cysts and the dis- tinction between peroneal intraneural and extraneural ganglion cysts (“transverse limb” and “signet ring” signs) at the superior tibiofibular joint with accura- cy and confidence.

Functional Effects of Locally Applied Thyroid Hormones in Sciatic Nerve Regeneration in Rats Institution where the work was prepared: National University of Athens, Athens, Greece Ioannis Papakostas, Dr1; Iordanis Mourouzis1; Kostas Mourouzis1; Constantinos Pantos1; Nikolaos Gerostathopoulos2; Dimitrios Ntallas, Dr3; George Macheras, Dr3; Efstathios Boviatsis, Dr4; (1)National University of Athens, (2)KAT Hospital, (3)1st IKA Hospital, (4)Evangelismos Hospital

Background: Thyroid hormones have long been debated for promoting peripheral nerve regeneration. Earlier experiments showed conflicting results. Those experiments were contacted with intraperitoneal injection of T3 in large quantities. This could had a detrimental effect through the systematic action of T3. Silicone chamber models with the instillation of T3 in the predefined area at the interstump gap can be used to study more efficiently T3 actions in peripheral nerve regenera- tion. Aim: Our aim was to study the functional effects of thyroid hormones in peripheral nerve regeneration through silicone chamber models in sciatic nerves of Lewis rats.

Material and Methods: 40 Lewis rats were randomized in four groups. The right sciatic nerve was transected at mid-thigh level and a 1cm silicone tube was used to bridge the gap which was 6mm. 12 rats were treated with a T3 solution inside the chamber, 12 rats were treated with a buffer solution, 8 rats received a sham operation and 8 rats had a 1cm segment excision with which was left unbridged. At three weeks intervals for 16 weeks a functional evaluation was conducted. Nociception with the withdrawal reflex and ankle stance angle were evaluated. A dynamic plantar aesthesiometer by UgoBasile was used for evaluations. Ankle stance angles were measured from video processing the gait patterns recorded in a Perspex runway by a digital camera.

Results: Ankle stance angles dropped sharply postoperatively and remained unaltered for the T3, Buffer and excision group. There were no differences between these groups. The sham group had no change postoperatively. Nociception as examined by the aesthesiometer showed a statistical significant difference between the T3 group and the buffer group. The T3 group had a more rapid improvement on this functional index. The excision group of rats showed no improvement at all.

Discussion: T3 had a substantial effect by promoting the return of nociception in rats that were treated with the hormone. Further studies with the use of the ground reaction forces are advocated to clarify the role of T3 in muscle reinnervation and function

128 Peripheral Nerve Injury in the Axolotl: a Model of Embryonic Regeneration Institution where the work was prepared: New York University School of Medicine, New York, NY, USA Stephen M. Russell, MD; Kartik Krishnan; Mark Schweitzer; Zehava Rosenberg; Moses Chao; New York University School of Medicine

Introduction: Following complete disruption of the nerve supply to the axolotl limb, a high degree of order, replicating the original pattern of nerve-muscle connections, has been reported. We hypothesize that, unlike in higher vertebrates, injured axons in the adult axolotl utilize embryonic mechanisms during regeneration. The aim of these preliminary experiments was to establish outcome measures of axolotl nerve regrowth in order to define the timing and completeness of reinnervation. Methods: Bilateral sciatic nerves in 36 axolotls were exposed: Group 1 (12 axolotls) left-side - sham, right-side – crush; Group 2 (12 axolotls) left-side – sham, right-side – nerve resected and proximal stump buried; Group 3 (12 axolotls) left-side – cut and sutured, right-side – cut and sutured with tibial and peroneal divisions reversed. Outcome measures included: (1) an axolotl sciatic functional index (ASFI) derived from video swim analysis, (2) motor latencies, (3) MR evaluation of nerve and muscle edema (T2, proton density, STIR sequences), and (4) retrograde neuronal labeling with horseradish peroxidase. Two axolotls per group were sacrificed at 0, 1, 2, 4, 6, and 12 weeks. Results: For crush injuries, the ASFI returned to baseline in 1 week, while MR parameters and motor latencies normalized by 2 weeks. For buried nerves, the ASFI returned to 20% below baseline by 8 weeks with evoked potentials being present. On MR, nerve edema peaked at 3 days and gradually normalized over 12 weeks, while mus- cle denervation was present until a gradual decrease was seen between 4 and 12 weeks. For cut nerves, the ASFI returned to 20% below baseline by week 4, where it plateaued. Evoked potentials were observed at 2 weeks, but with an increased latency until week 6, and MR analysis revealed muscle denervation until week 4. Reversing the sciatic divisions caused an approximate 3-week delay in all outcome measures. The retrograde axonal labeling results are pending. Conclusions: Multiple outcome measures using an axolotl model of peripheral nerve injury have been established. Axolotl recovery after nerve injury appears to occur earlier and is more complete than in rodents. Further investigation using this model as a successful “blueprint” for nerve regeneration in humans is warranted.

Sensory Protection Modulates Neurotrophic Factor Expression in Distal Nerve Stump Following Denervation Institution where the work was prepared: McMaster University, Hamilton, ON, Canada Margaret Fahnestock, PhD1; Bernadeta Michalski1; James Bain, MD, MSc2; (1)McMaster University, (2)Hamilton Health Sciences and McMaster University

Following peripheral nerve injury and in many neuromuscular disorders, the skeletal muscle atrophies and loses receptivity to the regenerating axon. We have shown that a sensory nerve sutured to the distal nerve stump during prolonged denervation significantly improves skeletal muscle morphology and function- al recovery (“sensory protection”). We are investigating the molecular changes accompanying sensory protection. Our previous studies showed that sensory pro- tection modulates neurotrophic factor levels in the muscle. Experimental evidence also shows that Schwann cells in the distal stump of axotomized neurons support axonal nerve regeneration by acutely upregulating neurotrophic factors following injury. However, neurotrophic factor regulation in the distal nerve stump during the longer periods required for motor nerve regeneration has not been examined. In the present study, we investigated if the distal nerve stump expresses neurotrophic factors for up to 6 months following denervation, and if sensory protection regulates this expression. The right gastrocnemius muscle of rat was denervated by transecting the tibial nerve, and either (1) the distal nerve stump was buried in the biceps femoris muscle to prevent regeneration (denervated group), (2) the saphenous nerve was sutured to the distal nerve stump (sensory protection group), or (3) the peroneal nerve was sutured to the dis- tal nerve stump (immediate motor repair group). The contralateral unoperated tibial nerve and tibial nerves from naïve animals were used as controls. We ana- lyzed brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF) neurotrophin-3 (NT-3), glial cell line-derived neurotrophic factor (GDNF) and cil- iary neurotrophic factor (CNTF) mRNA expression levels by real time RT-PCR in distal nerve stump. Denervation did not have long term effects on NGF or NT- 3 mRNA levels, nor was their expression affected by sensory protection. CNTF mRNA was highly expressed in intact control nerve, dramatically decreased start- ing from day 7 after surgery and remained at low levels for 3 to 6 months. BDNF and GDNF mRNA were barely detectable in intact control nerve, elevated in the immediate repair group and highly increased in denervated and sensory protection groups. Compared to denervated animals, sensory protection signifi- cantly lowered BDNF mRNA levels in distal stump at 1 to 3 months following denervation, and lowered GDNF mRNA levels at 1 month following denervation. These data suggest sensory protection normalizes BDNF and GDNF levels in distal nerve stump. Our current results suggest a role for sensory protection in altering neurotrophic factor mRNA expression in distal nerve stump following long term denervation.

The Source and Pattern of Motor Collateral Sprouting and Nerve Regeneration in End-to-Side Nerve Repair of Nerve to Medial Gastrocnemius in the Rat Institution where the work was prepared: Bernard O'Brien Institute of Microsurgery, Melbourne, Australia Alan Hussey, FRCS(Plast); Richard Brower; Aurora Messina; Wayne Morrison; Bernard O'Brien Institute of Microsurgery

In the presence of segmental nerve loss where direct end-to-end repair is not possible the options include nerve grafting, direct muscle neurotization, and nerve or tendon transfer to regain function. The possibility of end-to-side repair has already been explored experimentally and clinically.The advantage of this technique includes avoidance of the sacrifice of a donor nerve for grafting, and a reduced distance involved in reinnervation. The mechanism of axonal regeneration in this form of neurorrhaphy is still not understood. The purpose of this paper is to study this in an animal model. Twelve Sprague-Dawley rats were used. The nerve to the medial gastrocnemius (MGN) was ligated at 5 mm from its origin from the tibial nerve and divided to leave a long distal stump. An incision 0.5 mm long was made on the epineurium of the tibial nerve a minimum of 1 cm distal to the proximal stump of the divided MGN. The perineurium was left undisturbed. Silicone tubing was used to envelope both the MGN and the tibial nerve. This was used designed to minimize the possibility of aberrant fasicular linkage from outgrowth from the proximal nerve stump into the distal implanted nerve and facilitated later identification during re-exploration. Axonal regeneration was evaluated elec- trophysiologically and immunohistochemically. The results demonstrated contraction of the medial gastrocnemius muscle indicating that re-innervation had occurred. Microscopy of the tibial nerve between the stump of the MGN and the site of end-to-side repair revealed many axons in the epineurium. Many of these axons were partially myelinated. Sections through the site of anastomosis showed that the original tibial nerve remained intact and that injury was not the cause of axonal regeneration. The conclusion from this study is that regeneration arises from the divided axons of the proximal stump and travel distally down the tib- ial nerve to the site of the coaptation to re-innervate the medial gastrocnemius muscle.

129 A New and Novel Model of Peripheral Nervous System Response to Experimental Immunological Demyelination Institution where the work was prepared: University of California, Irvine, Orange, CA, USA Aaron M. Kosins, BS; Michael P. McConnell, MD; Charles Mendoza; Brandon Shepard; Sanjay Dhar, PhD; Gregory RD Evans, MD, FACS; Hans S. Keirstead, PhD; University of California, Irvine

Introduction: In order to investigate the remyelinating potential of mature Schwann cells in vivo in the peripheral nervous system, we have developed the first model of demyelination (nerve injury) in the adult rat sciatic nerve in which some Schwann cells survive demyelination. We also demonstrate, 1) Whether Schwann cells within a region of demyelination are induced to divide in the presence of demyelinated axons and 2) Whether fully-differentiated Schwann cells contribute to remyelination in the PNS. This data will be used to construct a model of enhanced nerve regeneration using neurons and Schwann cells derived from embry- onic stem cells.

Methods: Adult female Sprague-Dawley rats had their sciatic nerves exposed and injected with demyelinating agent bilaterally. At three, seven and fourteen days, the animals were euthanized following the onset of demyelination by aortic perfusion. The lesion containing length of nerve was cut into 1mm transverse blocks and processed to preserve the cranio-caudal orientation. The tissue blocks were postfixed, embedded in resin, and thin sections were cut and looked at under microscopy. A second group of animals was similarly lesioned and exposed to BrdU between 48-72 hours after the onset of demyelination. These animals were then euthanized soon after the last injection of BrdU. The tissue was examined to see whether surviving Schwann cells (labeled with S100 stain) could divide by measuring uptake of BrdU.

Results: A single epineural injection of complement proteins plus antibodies to galactocerebroside (the major myelin sphingolipid) resulted in demyelination followed by Schwann cell remyelination. At three days post-perfusion, peripheral sciatic nerve was clearly shown to begin the process of demyelination; however, Schwann cells did not take up BrdU. At seven days, demyelination peaked and the process of remyelination began but there was still little to no uptake of BrdU. At fourteen days, remyelination peaked and Schwann cells finally began to largely take up BrdU.

Conclusion: These studies demonstrate the first experimental immunologicalal model of demyelination and remyelination in the peripheral nervous system. The findings indicate that endogenous S100+ Schwann cells that survive within a region of demyelination in the adult rat sciatic nerve are not induced to divide by the presence of demyelinated axons. This leads to the possibility that remyelination is accomplished largely by Schwann cells that migrate in from the periphery. Future studies will use this data to create a model for enhanced nerve regeneration using neurons and Schwann cells derived from embryonic stem cells.

Demystifying Histomorphometry: A Serial Approach to Nerve Morphometry Institution where the work was prepared: Washington University School of Medicine, St. Louis, MO, USA Arash Moradzadeh, MD; Elizabeth L. Whitlock, BA; Susan E. Mackinnon, MD; Daniel A. Hunter, RA; Washington University School of Medicine

PURPOSE: Histomorphometry is the current gold standard for objective measurement of nerve architecture and its components. Despite the advances in computer soft- ware and histological techniques there remains wide variation in histomorphometric analysis. The goal of recently published techniques has been to combine the speed of automated morphometry with the accuracy of manual and semi-automated methods while only requiring basic digital imaging of sections and widely available software packages. While some of these methods are inexpensive, the deficiencies prevent thorough assessment of nerves. We will demonstrate that with appropriate technical training our approach is facile, rapid and comprehensive.

METHODS: The approach our lab developed in 1989 uses a series of binary imaging macros to measure all nerve fiber components including individual fiber area and width, axon area and width, and myelin area. We will compare our technique to recently published techniques attempting to use basic software and imaging systems, including design based stereology.

RESULTS: Recently introduced methods are only able to measure a limited number of morphological parameters, and rely on calculations for further detail. Direct meas- urement of parameters prevents the propagation of error inherent in calculating nerve parameters indirectly. The use of multi-bit planes incorporated in our software package allows us to carry out binary image analysis for the discrimination and segmentation of nerve fibers and nerve components with the addi- tion of mathematical morphology to exclude nonviable fibers and provide a measurement of fiber debris. Additionally, our program provides stratification of raw data by nerve component, complete statistical analysis and a graphical representation of fiber characteristics. In 15 minutes, 800 nerve fibers can be com- pletely evaluated.

CONCLUSION: Currently described techniques do not permit thorough analysis of nerve components by direct measurement. Our approach allows a more rapid, reproducible, and detailed assessment of nerve regeneration in various treatment modalities. Future integration of binary histomorphometric imaging and design based stere- ology techniques will augment our understanding of nerve regeneration.

130 Induction of Regional Collateral Sprouting Following Muscle Denervation Institution where the work was prepared: Washington University School of Medicine, St. Louis, MO, USA Arash Moradzadeh, MD; JW Koob, BA; Alice Tong; Ayato Hayashi, MD; Terence M. Myckatyn, MD; Thomas H. Tung, MD; Susan E. Mackinnon, MD; Washington University School of Medicine

BACKGROUND: Controversy exists regarding the ability of collateral sprouting to occur in the absence of epineurotomy in cases of end-to-side neurorrhaphy. In addition, pub- lished works report that collateral sprouting can be induced directly by denervated muscle. The current study evaluates the necessary conditions for the den- ervated masseter muscle to induce collateral axonal sprouting from branches of the facial nerve. We hypothesize that the chemotactic stimuli from denervat- ed muscle tissue will not induce collateral sprouting from nerves with intact epineurium.

METHODS: Transgenic mice expressing yellow fluorescent protein (YFP) under the control of neuron-specific elements from the thy1 gene were used to characterize the nature and extent of collateral sprouting through live imaging analysis. These mice were randomly allocated into “immediate” and “predegenerated” masseter muscle groups with subgroups undergoing varying degrees of injury to the marginal and buccal branches of the facial nerve: no injury, facial nerve crush, tran- section, or removal of a nerve segment. Mice were imaged weekly following injury to the facial nerve for a period of six weeks. At the endpoint, animals were perfused, acetylcholine receptors in the masseter muscle were stained with Alexa Fluor 488 alpha–bungarotoxin and muscle whole mounts were evaluated under confocal microscopy.

RESULTS: There was no evidence of collateral sprouting from axons in mice with intact or crushed facial nerve branches. Mice with transected branches of the facial nerve, or removed segments, demonstrated sprouting from the proximal nerve stump into the denervated masseter. Staining of the acetylcholine receptors con- firmed that new neuromuscular junctions were established between the sprouting axons from the facial nerve branches and the denervated masseter.

CONCLUSION: While further analysis is required to investigate the extent and nature of these neuromuscular junctions, this study provides evidence that denervated muscle does not provide sufficient stimulus to induce collateral sprouting from nerves with intact epineurium. Nerves with compromised epineurium may be useful in promoting neo-neurotization following muscle denervation when there is no possibility for nerve regeneration.

131 ASPN Scientific Paper Presentations C

A Novel Method of Head Fixation for the Study of Rodent Facial Function Institution where the work was prepared: Massachusetts Eye and Ear Infirmary, Boston, MA, USA Tessa A. Hadlock, MD1; Susan Mackinnon2; James T. Heaton, PhD1; (1)Massachusetts Eye and Ear Infirmary and Harvard Medical School, (2)Washington University in St. Louis

Inroduction: The rodent vibrissial system offers an excellent model for the study of both sensory and motor function. Existing methods of head fixation for precise meas- urements of ocular and vibrissial function are suboptimal, involving exposure of the cranium and the application of a piece of dental cement from which sev- eral threaded rods emerge. The purpose of this study was to create a simple head fixation device that minimizes the skin – foreign body interface, therefore improving biocompatibility, dramatically decreasing infection rates, and permitting essentially indefinite repeated measurements of facial function.

Materials / Methods: A template was designed to fit onto the calvarium of the rat, with holes positioned on the surface of the cranium, and located laterally to avoid penetration of sutures and dural sinuses. Then, a number of replicate devices were machined from surgical-grade commercially pure titanium. Four 250-400 g female Wistar rats underwent placement of the head fixation plates. Briefly, a midline incision was made in the scalp, and two small incisions corresponding to the location of the fixing posts were made. A subperiosteal plane was developed over the calvarium, the sterile plate was secured to the calvarium with 26 gauge surgical wire sutures, and the skin was closed. Animals were handled daily for 2 weeks prior to and 2 weeks after implantation of the devices. On POD#14, animals were removed from their cages, and the head was placed between two threaded fixation pins secured to a platform. The animals remained in the head fixed position for a ten minute period, during which they were rewarded with chocolate drink before being released and returned to the cages. Testing proceeded on a daily basis for the ensuing week, and then weekly for the ensuing month.

Results: There was no breakdown of skin overlying the implanted head plate in any of the animal. There was no obvious dural penetration of the surgical wires, and animal behavior was normal during the study period, with no gross motor or behavioral deficits.

Conclusions: We have described a novel method of head fixation that allows precise, repetitive measurements of both ocular and vibrissial function and can be stably main- tained for months. The use of a biocompatible implant largely eliminates the tissue reaction at the skin interface, and decreases infection risk. The device per- mits an unhindered view of whisker and eyelid movement, and leaves the superior surface of the cranium accessible for neurosurgical manipulation.

Small Fibers Dysfunction during Entrapment Neuropathy and after Surgical Decompression in a Rat Model Institution where the work was prepared: Ching-Hua Hsieh, Kaohsiung, Taiwan Ching-Hua Hsieh, MD1; Tsu-Hsiang Lu, BA1; Seng -Feng Jeng, MD2; Shun-Sheng Chen, MD, PhD1; (1)Chang Gung Memorial Hospital in Kaohsiung, (2)Chang Gung Memorial Hospital in Kaohsiung

Purpose: To investigate the small fibers dysfunction during entrapment neuropathy and after surgical decompression by skin biopsy with intra-epidermal nerve fibers density (IENFD) derived from quantification of PGP 9.5 immunoreactive epidermal nerve fibers and with immunohistochemistry of sensory receptor proteins substance P (SP) of the hindpaw skins in a established rat model of chronic nerve compression

Material and methods: Right sciatic nerve of the experimental SD rat was wrapped around with one inner diameter 1.3 mm silastic tube as an entrapment model. Sham operation was performed on the left sciatic nerve. As growing up of the rat, the sciatic nerve would become constricted by the tube and sustain neuropathy. Surgical decompression as removal of the silastic tube was performed six months later. Hindpaw skins of rats in indicated times (entrapment one, three, and six months, post decompression one and three months) were harvested for calculating IENFD and for immunohistochemistry of SP. Semisection with toluidine blue stain of the entrapped sciatic nerves were performed to evaluate the status of the myelinated fibers. Right hindpaw skins of naïve rats were used as a control.

Result: With progressive diminished SP-immunoreactive fibers, decrease of IENFD became more prominent in both hindpaws after entrapment one, three and six months (control: 20.04±2.26, 19.39±2.38, 20.45±2.40; experiment: 12.12±2.12, 6.27±1.02, 1.83±0.48; sham: 13.72±2.20, 8.59±1.37, 4.56±1.07 fibers/mm). The small fibers dysfunction was more obvious in the experimental hindpaw than in those of sham operation and naïve control. After decompression one and three months, increased IENFD in both sides were found (control: 20.38±2.24, 18.94±2.24; experiment: 7.00±1.14, 6.97±1.40; sham: 6.41±1.16, 9.92±1.64 fibers/mm). In addition, degeneration during entrapment and regeneration after decompression of the myelinated fibers were found in the semisection exam- ination.

Discussion: With remarkable improvement of postoperative clinical function and electrophysiologic values, surgical decompression often helps to ameliorate some of the pathologic change; however, conventional nerve conduction studies only detect abnormalities of large-fibre sensory nerves and offer no information regard- ing the status of small-fibre neuropathy. This study provided quantified and morphologic information regarding the cutaneous small fibers deficit during entrapment and after surgical decompression in a rat model. And it was of noted that not only the lesion side skin but also the contra-lateral side skin would present sensory deficit.

132 Harvested Human Neurons Engineered as Live Nervous Tissue Constructs: Implications for Transplantation Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA Eric L. Zager, MD; Jason H. Huang, MD; Jun Zhang, MD; Robert G. Groff, BA; Bryan J. Pfister, PhD; Eileen Maloney-Wilensky, CRNP; Akiva S. Cohen, PhD; M. Sean Grady, MD; Douglas H. Smith, MD; University of Pennsylvania

Object: Although neuron transplantation to repair the nervous system has shown promise in animal models, there are few imminent sources of viable neurons for clin- ical application and insufficient approaches to bridge extensive nerve damage in patients. Therefore, the authors sought a clinically relevant source of neurons that could be engineered into transplantable nervous tissue constructs. The authors chose to evaluate human dorsal root ganglia (DRG) neurons due to their robustness in culture.

Methods: Cervical DRGs were harvested from 16 live patients following elective ganglionectomies; and thoracic DRGs were harvested from 4 organ donor patients. Following harvest, the DRGs were digested in a dispase-collagenase treatment to dissociate neurons for culture. Remarkably, adult human DRG neurons, pos- itively identified by neuronal markers, survived at least 3 months in culture while maintaining normal electrophysiological behavior. In addition, dissociated human DRG neurons were placed in a specially designed axon expansion chamber that induces continuous mechanical tension on axon fascicles spanning two populations of neurons originally plated approximately 100µm apart. This process resulted in stretch-growth of the axon fascicles at the rate of 1mm/day to a length of 1 cm, creating the first engineered living human nervous tissue constructs.

Conclusion: These data demonstrate the promise of adult human DRG neurons as an alternative transplant material due to their availability, viability and capacity to be engineered. Also, these data show the feasibility of harvesting DRGs from living patients as a source of neurons for autologous transplant as well as from organ donors to serve as an allograft source of neurons.

In Vivo Bioluminescence Imaging of Schwann cells in a Nerve Conduit Institution where the work was prepared: Department of Plastic Surgery, Groningen, Netherlands M.S. Ma1; J.C.V.M. Copray1; G.M. van Dam2; H.W.G.M. Boddeke1; M.F. Meek, MD, PhD1; (1)University Medical Center Groningen, (2)UMCG-Department of Surgery

Background: Autologous nerve grafts remain a golden standard for repair of large peripheral nerve gaps. For bridging small gaps up to a few centimeters, nerve conduits can be used. However, there are no nerve conduits available for restoring larger nerve gaps. One promising method for bridging larger nerve gaps is the use of Schwann cells in long nerve conduits. Schwann cells supply the outgrowing proximal nerve fibers with trophic factors needed during regeneration. However, before Schwann cell coated long nerve conduits can be applied clinically, more knowledge has to be obtained about the longitudinal survival and functional- ity of these cells in vivo.

Aim: To evaluate the feasibility of longitudinal in vivo monitoring of transfected Schwann cell survival and functionality in a degradable nerve conduit using bio- luminescence imaging.

Methods: In order to accomplish longitudinal monitoring, we transfected rat Schwann cells transiently with the firefly luciferase gene. The transfected Schwann cells were seeded in a fibronectin/laminin coated CE and FDA approved nerve conduit. The seeded nerve conduit was implanted subcutaneously in a rat. Luciferase activ- ity of transfected Schwann cells was assessed using in vitro and in vivo bioluminescence imaging (IVIS). After explantation the nerve conduit was evaluated using scanning electron microscopy and immunohistochemistry.

Results: Our first results show that Schwann cells can be effectively transfected to express luciferase, do proliferate on a fibronectin/laminin coated degradable nerve conduit surface, and continue to express luciferase for at least 7 days after in vivo subcutaneous implantation."

Conclusion: Here we present the first proof of principle that we are able to longitudinally show Schwann cell survival and functionality in a degradable nerve conduit in vivo using Bioluminescence Imaging. This novel application has the advantage of allowing evaluation of nerve regeneration along with follow up of trans- planted cell survival, without the necessity of sacrificing experimental animals, by the use of bioluminescent multiple-reporter systems. We conclude that Bioluminescence Imaging can be an effective tool to evaluate Schwann cell applications in vivo.

133 Nerve Fiber and Motor Neuron Count Variation with Time After Nerve Injury Institution where the work was prepared: Washington University, Saint Louis, MO, USA Ida K. Fox, MD; Daniel A. Hunter; Susan E. Mackinnon; Washington University College of Medicine Purpose: The regeneration and subsequent remodeling of peripheral nerves remains a poorly understood process. After transection and repair or interposition grafting, the distal number of nerve fibers has been shown to change with time. The goal of this study was to assess both changes in the number of nerve fibers dis- tal to the repair and the corresponding number of retrograde labeled motor neuron cell bodies detected Methods: Lewis rat sciatic nerve underwent either transection and repair or interposition grafting of isologous sciatic nerve. Data was collected at 1, 3, 6, 9, 12 and 24 months post-procedure. To assess histomorphometric differences, peripheral nerve tissue distal to the repair or distal to the graft was collected. To quantify motor neuron regeneration, retrograde tracer was applied distal to repair site or interposed graft. Lumbar spinal cord ventral horn tissue was collected and the number of retrograde-labeled cell bodies in the ventral horn was counted. Results: Preliminary histomorphometric data shows augmentation then diminution in the number of distal nerve fibers with time. Overall, the transection and repair groups have more numerous distal fibers compared to the grafted group—this held true for all times points. The number of retrograde labeled motor neuron cell bodies showed a similar pattern of increase then decrease, however, the total numbers did not vary significantly between the two groups at the later times points. Conclusion: In studying nerve regeneration in the rodent model, the timing of outcomes assessment and nerve harvest is crucial. There is much to be learned about the regeneration of peripheral nerves, especially in regard to motor regeneration. This work serve as the basis for further investigation of motor regeneration dis- tal to transection or graft interposition-requiring injury.

Use of Skin-Derived Stem Cells to Promote Peripheral Nerve Regeneration and Recovery from Chronic Denervation Institution where the work was prepared: University of Calgary, Hotchkiss Brain Institute, Calgary, AB, Canada Sarah K. Walsh, BSc1; J. Biernaskie2; F. Miller2; Raj Midha, MD, MSc1; (1)University of Calgary, (2)University of Toronto Easily accessible sources for stem cell transplantation from skin dermis (termed skin-derived precursors, or SKPs) have been isolated from embryonic and adult murine skin (Toma et al., Nature Cell Biol, 2001) and have the ability to differentiate in vitro to neural crest cell types, including those with characteristics of peripheral neurons and Schwann cells. Our recent work (McKenzie et al., J. Neurosci., 2006) showed that naïve SKPs or those differentiated toward a Schwann cell-like phenotype (SKP-SCs) were able to survive and indeed myelinate regenerating axons in the crush-injured mouse sciatic nerve. In our ongoing study, we are exploring the ability of SKPs to remain viable and differentiate within a chronically denervated nerve in order to ascertain their role in promoting nerve regeneration. To this end, the sciatic nerves of CD-1 mice were transected and capped for 8 weeks to prevent reinnervation of the distal stump, creating a sit- uation of chronic denervation. Nerves were then repaired and SKPs or SKP-SCs (generated from GFP +ve mice according to Toma et al., 2001) were injected into the subepineurium distal to the transection. Immunohistochemistry and confocal microscopy 4-12 weeks following transplantation is expected to reveal survival and differentiation of both naïve and differentiated SKPs, represented as co-localization of GFP fluorescence and Schwann cell makers. Additionally, we expect to observe improved regeneration outcomes when compared to diluent controls. This study also examined the possibility of seeding synthetic guid- ance chambers with SKPs as a method of delivering a source of Schwann cells to nerve gaps often found in chronic denervation. Preliminary work in vitro shows that SKPs cultured within the lumen of chitosan tubes attach evenly to the walls and display morphology and protein expression consistent with that of Schwann cells. When SKP-seeded tubes are used to bridge a 5 mm gap in the mouse sciatic nerve, we expect that axonal regeneration through the tubes will be comparable to Schwann cell-seeded tubes, and significantly improved over empty conduits alone. We therefore conclude that SKPs represent an acces- sible, autologous source of stem cells for transplantation therapies that have potential to myelinate regenerating axons and improve regeneration outcomes in a chronic nerve denervation scenario.

Collagen Nerve Protectors in Rat Sciatic Nerve Repair: A Functional and Mechanical Analysis Institution where the work was prepared: Columbia University Medical Center, Department of Ortho. Surgery, New York, NY, USA Austin G. Hayes, BS; Charles M. Jobin, MD; Yelena Akelina, DVM; Melvin P. Rosenwasser, MD; Columbia University Medical Center Purpose: Peripheral nerve repair is often complicated by connective tissue proliferation, formation of perineural adhesions, and inhibition of gliding with subsequent nerve dysfunction. The use of bio-absorbable protective wraps may improve the functional outcomes of these repairs by inhibiting adhesions. Perineural scar and nerve tethering can be mechanically tested by stretching devices. This study analyzed the motor and sensory recovery and mechanical stiffness in tran- sected rat sciatic nerves repaired with and without tubular collagen nerve protectors. Methods: Thirty Sprague-Dawley rats underwent unilateral sharp sciatic nerve transection and repair with four epineurial sutures and were randomly treated with or with- out a circumferential collagen nerve protector, NeuraWrapTM. After ten weeks of healing, in vivo motor and sensory recovery was tested with extensor postur- al thrust, latency of limb withdrawal from noxious (56C hotplate) stimuli, and walking track analysis with calculation of sciatic functional index (SFI). Rats were then sacrificed and their sciatic nerves were stretched in situ with an Instron microtesting device at a rate of 20mm/min until failure. Force distraction curves were plotted and the stiffness and maximum load were calculated. As a final measure of muscle reinnervation, the percentage of gastrocnemius muscle weight lost between repaired and unoperated limbs was compared. Results: Of the thirty rats, two were sacrificed prior to testing, one due to infection (unwrapped), while another was lost during housing (wrapped). Significant differences exist- ed between repaired and uninjured nerves in nearly all measures. Functional recovery of repaired nerves was not significantly different between non-wrapped and wrapped nerves as measured by percentage extensor thrust deficit (82%, 86%), limb withdrawal time (4.2sec, 3.5sec), SFI (-57, -60), or percentage of gastrocnemius weight lost (45%, 47%). Mechanical testing also found no significant differences between non-wrapped and wrapped nerves in stiffness (0.55+/-0.14N-mm, 0.49+/- 0.13N-mm) and maximum load (2.97N, 2.70N). Repaired nerves, regardless of wrapping, were 1.4-fold stiffer than uninjured nerves (0.37+/-0.13N-mm) (p<0.05). Conclusions: The use of collagen nerve protectors yielded functionally and mechanically similar outcomes compared to traditional suture repair in sharply transected rat sciatic nerves. Although the collagen nerve protector reduced nerve stiffness it was not significantly different from unwrapped nerves. This small reduction correlated with previous studies that found decreased perineural scar thickness distal to the repair site with the use of collagen wraps. Clinically, the use of collagen nerve protectors during pri- mary repair of peripheral nerve transections may likely yield no substantial functional or mechanical advantage although small improvements may exist.

134 In Vivo Enhancement of Spinal Axon Outgrowth by Sialidase in a Rat Model of Brachial Plexus Avulsion Institution where the work was prepared: Johns Hopkins School of Medicine, Baltimore, MI, USA lynda js Yang, MD, PhD; University of Michigan Hospitals; Ronald Schnaar, PhD; The Johns Hopkins University

The adult CNS is an inhibitory environment for axon outgrowth, severely limiting recovery from traumatic injury. This is due, in part, to endogenous axon regener- ation inhibitors (ARI's) that accumulate at CNS injury sites. ARI's may bind to complementary receptors on the axon growth cone to halt axon outgrowth. ARI's include myelin-associated glycoprotein, Nogo, OMgp, and chondroitin sulfate proteoglycans. Reversing or blocking the actions of ARI's may promote recovery after CNS injury. We report that treatment with sialidase, an enzyme that cleaves one class of axonal receptors for the ARI myelin-associated glycoprotein, enhances spinal axon outgrowth into implanted peripheral nerve grafts in a rat model of brachial plexus avulsion, a traumatic injury in which nerve roots are torn from the spinal cord. Repair using peripheral nerve grafts is a promising restorative surgical treatment in humans, although functional improvement remains limited. To model brachial plexus avulsion in the rat, C8 nerve roots were cut flush to the spinal cord and a peroneal nerve graft was inserted into the lateral spinal cord at the lesion site. Infusion of Clostridium perfringens sialidase to the injury site increased the number of spinal axons that grew into the graft markedly (2.6-fold). Chondroitinase ABC, an enzyme that cleaves a different ARI (chondroitin sulfate proteoglycans), also enhanced axon outgrowth in this model. In contrast, phosphatidylinositol-specific phospholipase C, which cleaves OMgp and Nogo receptors, was without benefit. Molecular therapies targeting sialoglycoconjugates and chondroitin sulfate proteo- glycans may aid functional recovery after brachial plexus avulsion and perhaps other nervous system injuries and diseases.

Effects of Motor Versus Sensory Nerve Architecture on Regeneration Through Cold Preserved Nerve Grafts Institution where the work was prepared: Washington University School of Medicine, St. Louis, MO, USA Arash Moradzadeh, MD; Christopher M. Nichols, MD; Jason W. Koob, BA; Daniel A. Hunter, RA; Susan E. Mackinnon, MD; Washington University School of Medicine Purpose: Autologous nerve grafting is the current standard of care for nerve injuries resulting in a nerve gap. This treatment requires the use of sensory grafts to reconstruct motor defects. Recent work has shown that pure sensory nerve grafts have an inferior regenerative capacity in comparison to nerve repair using motor and mixed grafts. These results suggest that nerve grafts containing motor elements confer a growth advantage to regenerating motor neurites. The exact mechanism of this regeneration differential remains unclear. This phenomenon may be due to either a difference in the cellular/molecular milieu created by the presence of motor ele- ments in the mixed and motor grafts, or it may be due to a difference in the physical architecture of the motor graft segments which is conducive to motor nerve regeneration. In order to further define this mechanism, our study investigated nerve regeneration through acellularized nerve grafts of motor and sensory origin. Methods: Lewis rats underwent tibial nerve transection and received 5mm isogeneic motor or sensory nerve grafts. Nerve grafts were harvested and treated with 7 weeks of cold preservation in University of Wisconsin solution to effectively acellularize the grafts, leaving only the laminin ultrastructure of the Schwann cell basal laminae tubes. Control animals received identical 5mm fresh motor or sensory isografts. Nerve grafts were harvested at a 4 week endpoint and histomorphometric analysis of the regen- erating nerves was conducted for comparison. Electron microscopy of the sensory and motor grafts was also conducted to delineate baseline architectural differences. Results: Histomorphometric analysis of nerve grafts reveals more robust nerve regeneration in the cold preserved motor grafts in comparison to the cold preserved sen- sory allografts. The regeneration was improved in the motor groups both in terms of total fiber counts and fiber width, implying more mature neurites and more advanced regeneration in the motor group. Conclusions: Our results suggest that nerve architecture does play an important role in regeneration of nerves through grafts of differing modalities. These results bring in to question the hypothesis that cellular interactions are responsible for the growth differential seen in modality matched nerve grafts. Ultrastructure and archi- tecture may play a more important role in nerve regeneration than previously recognized.

Live Image Analysis of Schwann Cell-Axonal Relationship in Peripheral Nerve Allografts Institution where the work was prepared: Washington University in St. Louis School of Medicine, St. Louis, MO, USA Ayato Hayashi; Terence M. Myckatyn, MD; Alice Y. Tong, MS; Daniel A. Hunter, RA; Daniel Z. Liu, BA; Jason W. Koob, BA; Arash Moradzadeh, MD; Jamie D. Gaertner; Thomas H. Tung, MD; Susan E. Mackinnon, MD; Washington University in St. Louis

Background: Recent advances in molecular neurobiology have led to transgenic mice that express genes encoding fluorescent proteins under neuron-specific or Schwann cell-specific promoters. By using these mice we can monitor regenerating axons or migrating Schwann cells in live animals, visually evaluating these processes without specific staining. Method: To study the rate of Schwann cell migration and axonal regeneration into a nerve allograft, we have developed double-transgenic mice called S100-GFP/Thy1- CFP mice. These mice have Schwann cells that constitutively express green fluorescent protein (GFP) and axons that express cyan fluorescent protein (CFP). These mice received allografts from non-fluorescing C57BL/6J mice. Nerve grafts devoid of fluorescence provided a unique opportunity for serially studying nerve regeneration and Schwann cell migration into the graft since any fluorescence noted within the grafts was derived from host murine nerve. Animals were randomized into four treatment groups. In one group, the nerve allograft was transplanted without any additional treatment. In the second, the donor nerves were cold preserved for seven weeks. In the third, mice were treated with FK 506 to eliminate the direct pathway of nerve allograft rejection. In the fourth group, mice were treated with anti-CD40 and CTLA4-Ig to block the costimulatory pathway of nerve allograft rejection. The allograft was serially imaged by a fluorescent dissecting microscopy every 5 days, and the intensity of fluorescence was measured with the line scanning algorithm. To investigate Schwann cell viability in the allograft, we also performed the allografts in a reverse fashion. C57BL/6J mice also received allografts from fluorescing S100-GFP mice. Furthermore, a more detailed characterization of immature Schwann cells utilizing Nestin-GFP mice is pending. Results: The results demonstrate that untreated allografts are characterized by significant host Schwann cell migration, while immunosuppression preserved donor Schwann cells. FK506 treated allografts showed the fastest regeneration through the graft. In the flipped allograft, GFP expression in the untreated allograft lost by 28 days after transplantation. Conclusion: From these results, we suspect that a nerve allograft, devoid of Schwann cells, will induce dedifferentiation and migration of host Schwann cells into the graft.This study represents a novel model for studying Schwann cell migration and axonal regeneration at multiple time points and provides the characteris- tics of migrating adult Schwann cells.

135 Multiple Costimulatory Pathway Inhibition for Nerve Allograft Regeneration Institution where the work was prepared: Washington University in St. Louis School of Medicine, St. Louis, MO, USA Chau Y. Tai, MD; Jaime Gaertner; Dan A Hunter; Thomas H Tung; Washington University in St. Louis

Background Full T cell activation requires recognition of foreign antigen by the T cell receptor and the ligation of costimulatory molecules. Blockade of the CD40 and B7/CD28 costimulatory pathways has been most extensively studied and significantly improves allograft survival. We have previously shown that the blockade of both pathways improved regeneration across the peripheral nerve allograft after a short course of therapy but with suboptimal results compared to isograft controls. The inducible costimulator (ICOS) is a recently recognized member of the CD28 family with overlapping as well as independent and complimentary roles in T cell activation, and has shown promise in improving allograft survival when combined with either CD40 or CD28 blockade. We hypothesize that triple blockade of T cell costimulatory pathways will further improve regeneration through the peripheral nerve allograft in the murine model.

Methods: One centimeter sciatic nerve allografts were transplanted from Balb/c donors to C57bl/6 recipients. C57bl/6 isograft recipients without immunosuppression served as controls (Group I, n=6). Allograft animals received a double-blockade regimen, CTLA4-Ig + MR1 (Group II, n=4) or a triple-blockade regimen, CTLA4- Ig + MR1 + anti-ICOSLmAb (Group III, n=5) on postoperative days 0, 3, and 6.

Costimulatory Pathway Blockade Agent Dose 1) CD28/B7 CTLA4-Ig 0.5mg 2) CD40/CD40L MR1 1 mg 3) ICOS/B7h anti-ICOSLmAb 0.5mg

The animals were sacrificed 3 weeks postoperatively. Spleens cells were used in ELISPOT assays for interferon-gamma, and results were recorded as spots per millions cells (SPMC). Total number of nerve fibers (TNNF) regenerated in the graft segments were examined at midgraft level for all groups.

Results: Mean ELISPOT reactivity to the donor in Groups I, II, III were 10, 38, and 13.45 SPMC, respectively (ns). Concavalin-A control positive reactivity was 360 SPMC. Mean total number of nerve fibers were 2163, 825, and 2063 (p<0.05), respectively.

Conclusions: ELISPOT results showed minimal response of the transplanted recipient to donor antigens in both experimental groups. TNNF showed regeneration in both experimental Groups II and III, with excellent regeneration in Group III comparable to that of the isograft. Short course triple-blockade of the T-cell costimu- latory pathways yielded superior regeneration in nerve allografts compared with previous combinations of agents. This provides a promising approach for the temporary immunosuppressive requirements for the peripheral nerve allograft.

A Dose Dependent Facilitation and Inhibition of Early Peripheral Nerve Regeneration by Nerve Growth Factor (NGF) Through a Novel T-tube Chamber: Effects on the Establishment of an In Vivo Concentration Gradient Institution where the work was prepared: University of Calgary and the Hotchkiss Brain Institute, Calgary, AB, Canada Stephen W.P. Kemp, BSc(Hons), MSc; Sarah K. Walsh, BSc; Douglas Zochodne; Raj Midha, MD, MSc; University of Calgary

Previous research has examined the application of exogenous neurotrophic factors (NTFs) to the microenvironment of the injured nerve, attempting to pro- duce a situation similar to that of target organ reinnervation. However, placement of NTFs within the lumen of nerve guidance tubes has resulted in variable regenerative success, perhaps owing to poor bioavailability or a lack of delivery of concentration gradients of NTFs, which are critical in in vitro studies. We hypothesized that either a time-released or gradient delivered profile of NTFs would influence in vivo axonal regeneration. We sought: (1) to determine the most effective dose of nerve growth factor (NGF) on early sciatic nerve regeneration in the rat using a novel T-tube conduit paradigm (McDonald & Zochodne, 2003), and; (2) to establish a chemotactic concentration gradient utilizing the appropriate dose of solube NGF in the T-tube model. Animals were randomly assigned to one of five drug treatment groups (saline, 200, 800, 1600, or 2400 pg NGF). Injections were administered through the use of a microinjection port (MIP) connected to a silicon based T-tube chamber. Analysis of early axonal outgrowth was performed by counting neurofilament positive profiles within lon- gitudinal sections of the proximal stump through the regenerating nerve bridge. We subsequently examined the ability of the T-tube model to establish a con- centration gradient of NGF within its lumen, assessed by ELISA. Results of the study indicate that administration of NGF through a novel T-tube paradigm promoted a dose-dependent facilitation and inhibition of early peripheral nerve regeneration, with animals administered 800 pg NGF displaying a significant- ly greater neurofilament profile within the nerve cable than any other group (p<.05). In subsequent studies, we found a significant multivariate effect for the interaction of time x location x group (p<.05), indicating that a chemotactic concentration gradient of NGF can be established depending on the placement of the T-tube catheter (proximal, middle, or distal location) over a transient time period, and can be re-established with repeated daily administrations of NGF. Current results implicate that administration of NGF at a dose of 800 pg is optimal for enhancing early peripheral nerve regeneration. This dose, when utilized in a novel T-tube chamber conduit model, can reliably establish daily concentration gradients of NGF. Ongoing studies are using this novel delivery system to assess the effect of an imposed concentration gradient of soluble NGF on long-term analysis of peripheral nerve regeneration in vivo, including electrophysi- ological and functional recovery analysis.

136 An Alternate Nociceptive Drive: The Role of Afferent-Efferent Propioceptive System in the Maintenance of Chronic Pain States Institution where the work was prepared: Hand and Microsurgery Center of El Paso, El Paso, TX, USA Jose Monsivais, MD; Hand & Microsurgery Center; Kris Robinson, PhD, FNP; University of Texas at El Paso

Neck, hip, and upper/lower limb pain often persist following adequate nerve decompression. Such symptoms are frequently dismissed or attributed to soma- tization and ignored. Frequently these patients exhibit abnormal muscle activity (dystonias, spasms, etc.) not explained by other pathology. This paper is the translation of 10 years of laboratory and clinical findings.

A relationship exists between endonerual pressure and abnormal muscle activity. Earlier research demonstrated abnormal muscle activity by EMG in the sca- lene muscles followed by response of the supraspinatus, rhomboids, deltoids, ECRL, and ERCB as a result of increased endoneural pressure >40 mm/hg in medi- an/ulnar nerves of Nubian goats. As the pressure increased above 100 mm/hg the response was seen in the same muscles on the contralateral side. Subsequently, this phenomenon was observed originating from the radial nerve and noted between the sciatic and tibial nerves and iliospsoas, pyriformis, and gluteus mus- cles of laboratory animals and humans.

With endoneural pressure exceeding 40 mm/hg nociception originates from the ipsilateral peripheral nerve by activation of A-delta and C fibers to dorsal root ganglia and spinal cord to the reticular formation (spinal reticular tract) and cerebellum. When pressures exceed 100 mm/hg, the afferent response crosses the midline (spinal cord, medulla) and triggers abnormal muscle activity in homonymous muscles in the contralateral side indicating that it most likely originates in the same spinal segment, that the propioceptive system is involved, and that the efferent activity originates at subcortical level as we have observed this to occur under light anesthesia in humans and laboratory animals. This is one possible mechanism for the mirror image expression of pain.

In summary, a reverberating afferent-efferent loop is activated that starts with peripheral receptors (transduction) travels along the spinal cord (transmission) to the midbrain (modulation), cerebellum or sensory cortex (perception) with a motor activity (response). However, prolonged efferent activation generates mus- cle damage through persistent muscle contraction which in turn induces afferent nociceptive impulses by activation of propioceptive receptors and dorsal horn sensitization. This response induces further muscle activity which triggers further nociception and response. Once this point is reached and the somatic-gamma propioceptive loop closes, nerve decompression may not be sufficient to resolve the pain state. We suggest that this cascading and chronic response induces activity that maintains pain and, at this point, is independent of endoneural pressure. Thus, the propioceptive system becomes a nocioceptive drive.

Effect of Levetiracetam and Morphine in an Animal Model of Neuroma Pain Institution where the work was prepared: Johns Hopkins, Baltimore, MD, USA Lun Chen; Richard Meyer; Michael Dorsi; Allan J. Belzberg, MD; Johns Hopkins University

An injury to a peripheral nerve may lead to the development of a neuroma where mechanical stimulation of the neuroma leads to painful paresthesias. The antinociceptive effect of antiepileptic drugs have been reported in neuropathic pain syndromes. In this study we compared the effect of levetiracetam to that of morphine on reducing the pain behavior associated with mechanical stimulation of a neuroma in the rat tibial neuroma transposition (TNT) model.

Methods: In male Sprague-Dawley rats (250-300g), the left tibial nerve was exposed, tightly ligated with 6-0 silk, and cut just proximal to the division of the medial and lateral plantar nerves. A subcutaneous tunnel was created to a location 1-3 mm superior to the lateral malleolus. The tibial nerve stump was passed through the tunnel to the lateral site. A blinded experimenter applied a 150 mN von Frey filament to the ligature site (visible through skin). A score is assigned based on the frequency of paw withdrawal to five applications of the von Frey probe. In addition, graded von Frey filaments were applied to the sites on the later- al surface of the hindpaw corresponding to the sural nerve territory. Paw withdrawal thresholds to mechanical stimuli were obtained at these sites. Animals received a systemic administration (i.p.) of levetiracetam (20, 40, 100, 200, 400 mg/kg), morphine (0.5, 1, 2, 4, 8 mg/kg), or vehicle in a blinded, random fash- ion. Behavioral testing was performed before surgery, day 6 postoperative, and then on drug delivery days 9 and 15 postoperative. A given animal was tested with one dose of each drug (with at least a two day wash out period). Each dose was tested on eight animals.

Results: Mechanical stimulation to the skin overlying the neuroma with the von Frey probe provoked a rapid withdraal of the hindpaw in 96% of the animals, 6 days after neuroma surgery. Hyperalgesia to mechanical stimuli applied to the sural nerve distribution was demonstrated in 86% of animals 6 days after surgery. These behaviors were not affected by the systemic administration of vehicle or levetiracetam. In contrast, administration of morphine led to a dose-dependent decrease in the frequency of paw withdrawal to mechanical stimulation of the neuroma and increase in paw withdrawal threshold to stimulation of the paw.

Conclusion: These results indicate that levetiracetam, in contrast to morphine, does not induce an antihyperalgesic effect in the TNT model of neuroma pain.

137 The Effect of Cold Storage on Somatosensory Function of Allogenic Nerve Transplants Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Michal Molski; Yalcin Kulahci; Ilker Yazici; Maria Siemionow; Cleveland Clinic

INTRODUCTION: For reconstruction of severe nerve defects in which primary repair of the nerve is impossible, there is a significant need to provide adequate amount of nerve graft material for the best outcome. Nerve allografts can overcome these difficulties providing unlimited supply and no donor site morbidity, but immunosu- pression may be necessary. However when allogenic nerve grafts are preserved by cold storage, they may become less antigenic and more functional.

PURPOSE: To compare the functional outcome of the cold stored nerve isografts (CSNI) and cold stored nerve allografts (CSNA) following rat sciatic nerve gap repair.

MATHERIAL AND METHODS: 12 Lewis rat recipients were divided into 2 groups of 6 animals each. Nerve grafts were harvested from BN rats (n=6) and Lewis rats (n=6), and stored in UW solution for 21 days in +4C. A 25mm gap was created in recipient's sciatic nerve and defect was bridged with CSNI in group 1 and CSNA in group 2. Recipients of allografts received 7 day protocol of ??TCR and CsA. Nonoperated sites served as normal controls. Nerve regeneration was evaluated by pin prick and toe spread at 3, 6, 12, 24 weeks and by somatosensory evoked potentials examination (SSEP) at 12 and 24 weeks post-transplant. At last observation gastrocne- mius muscle index was achieved. Statistic analysis was performed using Mann-Witnney test.

RESULTS: At all observations pin prick score in both groups was 3. Average toe spread score in both groups reached the same values at 3, 6, 12, 24 weeks: (0, 1, 2, 2.8) respectively. SSEP (latencies; % of normal values): at 12 weeks CSNI (17.8, 26.5; 85%, 80%), CSNA (19.9, 28.4; 87%, 80%) at 24 weeks: CSNI (17.6, 24.5; 82%, 87%), CSNA (17.4, 25.7; 82%, 79%). Gastrocnemius muscle weight on the allografted side reached 60% of control side in CSNI group and 42% in CSNA group.

CONCLUSIONS: Cold storage of allogenic nerve grafts opens a new horizon in peripheral nerve reconstructive options. Nerve gap repair with allogenic cold stored nerve grafts (CSNA) followed by short term immunosupression protocol (7 day protocol of ??TCR and CsA) resulted in a good functional outcome comparable to cold stored nerve isograft (CSNI) transplants.

The Behavioral and Immunological Effect of GM-1 Ganglioside on Nerve Root Regeneration Following C5 Nerve Root Avulsion In a Rat Model Institution where the work was prepared: Rush University Medical Center, Chicago, IL, USA Harold Gregory Bach, MD1; Heather Harrison, BS2; Bassem El Hassan, MD3; James M. Kerns, PhD2; Robert M. Leven, PhD2; Mark Gonzalez, MD1; (1)University of Illinois at Chicago, (2)Rush University Medical Center, (3)Mayo Clinic

Purpose: This study investigated the effect of GM-1 ganglioside treatment on nerve regeneration following nerve root avulsion in a rat model. This study also assessed autoimmune responses to GM-1 ganglioside treatment.

Significance: A brachial plexus injury involves damage to the nerve roots and nerves at or near their exit from the spinal cord. The most devastating lesions are those prox- imal to the dorsal root ganglion that can be associated with avulsions of the spinal cord, loss of anterior horn cells and syrinx formation. In many nerve root avulsions however, the anterior horn cell is preserved and is capable of regenerating motor axons. This makes recovery of motor function possible even in pre- ganglionic root avulsion injuries. Nerve root avulsion due to traction may occur at birth or from trauma. After brachial plexus injury, enhanced motor sprout- ing after nerve root avulsion holds promise to improve outcomes. It is postulated that GM-1 ganglioside stimulates neuronal sprouting and enhances the action of nerve growth factor. GM-1 ganglioside has been shown to enhance recovery of motor function following spinal cord injury in humans. Immune responses, marked by the presence of anti-GM-1 antibodies, have been reported following GM-1 ganglioside therapy.

Methodology: A rat model of C-5 nerve root avulsion causing immediate paralysis of biceps function was created. The Bertelli grooming test asseses return of biceps func- tion. Sixty-four adult male Sprague-Dawley rats were separated into 4 treatment groups of either C5 nerve root avulsion with or without GM-1 ganglioside treatment for 30 days or C4-C5 hemilaminectomy with or without GM-1 ganglioside treatment. The Bertelli grooming test assessed functional recovery. To evaluate for the presence of anti-GM-1 antibodies, serum was collected from 44 rats prior to sacrifice for ELISA testing.

Results: The Bertelli grooming test revealed no significant functional improvement in the rats treated with GM-1 ganglioside; 44% of GM-1 ganglioside injected rats attained a good functional outcome compared to 50% for the controls. ELISA testing revealed that the probability of developing an immune reaction by for- mation of anti-GM-1 antibodies was 17%. Histological examination found no evidence of neuropathy or inflammation in any of the rats.

Conclusions: GM-1 ganglioside did not improve biceps function after C-5 nerve root avulsion in a rat model. Immunological testing revealed that 17% of treated rats devel- oped anti-GM-1 antibodies, which could portend a risk regarding its use. This may explain an increase in the incidence of Guillain-Barre Syndrome in patients given GM-1 ganglioside.

138 Cryopreservation of Epineural Sheath Conduits Gives Similar Functional Results as Cold Storage Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Michal Molski; Yalcin Kulahci; Ilker Yazici; Maria Siemionow; Cleveland Clinic INTRODUCTION: For reconstruction of long nerve defects, more autograft material is needed. Allogenic nerve transplantation (ANT) provides access to unlimited sources of nerve grafts but requires immunosuppression. To reduce nerve immunogenicity, cold preservation was used in the past. Epineural sheath allotransplantation provides unlimited amount of grafting material, but cold storage is time limited. Epineural sheaths storage in cryogenic conditions will increase availability of grafting material and will allow for unlimited nerve banking. PURPOSE: To compare the effect of cold storage (CS) and cryopreservervation (CR) of isogenic and allo- genic epineural sheaths (ES) on functional outcome following rat sciatic nerve gap repair. MATHERIAL AND METHODS: 24 Lewis rat recipients were divided into 4 groups of 6 animals each. ES were harvested from Brown Norway rats (n=12) and Lewis rats (n=12), 6 isogenic and 6 allogenic grafts were stored in UW solution for 21 days in +4C, remainder were cryopreserved in liquid nitrogen. A 25mm gap was created in recipient's sci- atic nerve and defect was bridged in following group: 1) with cold stored isogenic ES; in group 2) cold stored allogenic ES; in group 3) cryopreserved isogenic ES; and in group 4) cryopreserved allogenic ES. Recipients of allografts received 7 day protocol of ??TCR and CsA. Non-operated contralateral sites served as normal controls. At 24 weeks nerve regeneration was evaluated by pin prick, toe spread test somatosensory evoked potentials examination (SSEP) and gastroc- nemius muscle index (GMI). RESULTS: There was no difference in pin prick between groups. Toe spread results were 2.7; 1.0; 3.0; 1.4 in group 1,2,3 and 4 respectively. When compared to normal values SSEP result were 89%; 87%; 93%; 89% in group 1,2,3 and 4 respectively. Gastrocnemius muscle index values were 21%; 28%; 18.4%; 18.2% in group 1,2,3 and 4 respectively when compared to muscle weight of control side. CONCLUSIONS: Repair of 25mm gap of rat sciatic nerve with cryopreserved allogenic epineural sheath grafts resulted in functional results comparable to cold stored allogenic epineur- al sheath grafts. In isogenic groups functional recovery in cryopreserved epineural sheath group was better comparable to cold storaged group. Cryopreservation may be more applicable method for storage of nerve allogenic material since it allows for longer graft storage with comparable functional outcome after

Outcome of Neurolysis for Failed Tarsal Tunnel Syndrome Institution where the work was prepared: Johns Hopkins University, Baltimore, MD, USA A. Lee Dellon, MD1; Allison R. Barker, BA2; Gedge D. Rosson1; (1)Johns Hopkins University, (2)Johns Hopkins University School of Medicine While surgery to treat median nerve compression and failed carpal tunnel decompression is well-described, experiences with decompressing the tibial nerve in the tarsal tunnels are not well-described. There have only been two reports of the treatment of failed tarsal tunnel surgery. This is the largest reported series of tarsal tunnel revision surgery reported. Revision tarsal tunnel surgery was performed on 44 patients (two bilaterally). The surgical procedure included a neurolysis of the tibial nerve in the tarsal tun- nel, the medial plantar, lateral plantar, and calcaneal nerves in their respective tunnels, and excision of the inter-tunnel septum. For patients with an associat- ed painful scar, neuroma resection of the posterior branch of the saphenous nerve and/or resection of a calcaneal nerve branch, plus muscle implantation, was included. Post-operatively, immediate ambulation was permitted. Outcomes were assessed were assessed by someone other than the surgeon, with a numerical grading scale that included neurosensory measurements (0 = nor- mal, 10 = most severely impaired). Outcomes were also assessed by patient satisfaction and their own estimate of residual pain and/or numbness. Mean fol- low-up time was 2.2 years. (range 1 to 4 years). Results in terms of patient satisfaction were 54% excellent, 24% good, 13% fair, and 9% poor results. Results in terms of numerical grading demonstrated a significant improvement (p<0.001) from a pre-operative mean of 5.96 to a post-operative mean of 2.74. Prognostic indicators of poor results in our patient group were coexisting lumbosacral disc disease and diabetic neuropathy. Conclusion: For patients with previously failed tarsal tunnel surgery for nerve compression, a surgical approach that includes neurolysis of the tibial nerve and its branches in four medial ankle tunnels, combined with resection of cutaneous neuromas in the scar, and a post-operative regimen of early mobilization can give significant pain relief, recovery of sensibility, and improved foot function for this disabling clinical problem.

Prospective Comparison of Electrodiagnostic and Neurosensory Testing in Patients with Neuropathic Symptoms of Lower Limbs Institution where the work was prepared: Chicago Peripheral Nerve Center, Chicago, IL, USA Roberto P. Segura, MD; Edgardo R. Rodriguez; Chicago Peripheral Nerve Center Background: Traditional electrodiagnostic testing(NCS/EMG)has been reported as having low sensitivity in detecting lower limb peripheral nerve problems, whereas neurosensory testing with the Pressure-Specified Sensory Device(PSSD)has shown high sensitivity. A prospective study comparing these two modalities has not been reported. Method: Patients with lower limb peripheral nerve complaints from a Podiatric Foot and Ankle Surgery practice were referred to a Neurologist specially trained in periph- eral nerve disorders for diagnostic evaluation. Detailed nerve conduction studies were performed and included testing of tibial and peroneal motor nerves, as well as sensory testing of sural, superficial peroneal, medial plantar and calcaneal branches. The PSSD was performed by a trained technician and the results interpreted by the Neurologist. The findings of the first 20 patients are presented at this time. The breakdown of conditions was: 3 diabetics and 4 nondia- betics with bilateral foot symptoms, 11 post-traumatic patients with unilateral symptoms, and 2 patients with lumbar radiculopathy and foot symptoms. Results: 19 of the 20 patients demonstrated abnormalities of both NCS and PSSD. All PSSD studies showed alterations of 1 and 2 point static measurements. Only 1 patient with bilateral foot symptoms of nondiabetic origin showed an abnormal PSSD to 1 point measurement and a normal NCS. Conclusion: We have found a good correlation between detailed NCS and PSSD findings in patients with lower limb neuropathic symptoms. Previous reports alluding to low sen- sitivity of NCS may be due in part to methodologies that failed to include detailed study of distal sensory branches. Even though the PSSD lacks specificity regarding the anatomical site of the lesion, it can be of great value to follow the course of illness once a baseline NCS has demonstrated focal peripheral nerve dysfunction.

139 ASRM Concurrent Scientific Paper Presentations A-1

The Use of Three-Dimensional CT Angiography for Preoperative Mapping of Abdominal Wall Perforating Vessels for Autologous Perforator-Based Microsurgical Breast Reconstruction Institution where the work was prepared: Johns Hopkins University School of Medicine, Baltimore, MD, USA Christopher G. Williams, MD; Navin K. Singh, MD; Elliot K. Fishman, MD; Gedge D. Rosson, MD; Johns Hopkins University School of Medicine

Background: Since the first report of TRAM flap reconstruction after mastectomy, there have been numerous studies on how to reduce the complication rates of elective breast reconstruction. Current methods of preoperative perforator localization can be time-consuming, inaccurate, and imprecise. Thus, we sought to evaluate the use of Ultra-high resolution 3-D CT angiography for the preoperative mapping of abdominal wall perforating vessels for use in microsurgical free flap autol- ogous tissue breast reconstruction.

Methods: We conducted an IRB-approved review of all perforator-based autologous tissue breast reconstruction patients at The Johns Hopkins Hospital Avon Foundation Breast Center between October 19, 2005 and March 19, 2006. Those women who were candidates for DIEAP flap reconstruction had been sent for a focused CT scan of the abdominal wall perforating blood vessels, using the 64 slice multi-detector CT scanner. The CT angiogram was then used as a roadmap for operative planning and intra-operative dissection. Many women lived out of town and could not return for the CT scan.

Results: During this 5 month period, 86 perforator flaps were planned, and 82 performed. This paper presents the results of the first 23 flaps in 17 patients with pre- operative ultra-high resolution 3-D CT angiography for the evaluation of their abdominal wall perforating vessels on which the planned DIEAP flaps would be based. The preoperative plan was changed in three patients (five flaps): to SIEA in two patients, and laparoscopic cholecystectomy in another. Of the 63 planned perforator flaps in patients without 3D CT scans, four flaps were intraoperatively aborted, while no flaps were intraoperatively aborted in the CT scan group. There was one takeback for early venous congestion due to pedicle kinkage, no flap loss, and no fat necrosis in the CT scan group. Pre- and post-operative creatinine levels were unchanged.

Conclusions: Preoperative perforator flap planning for breast reconstruction utilizing ultra-high resolution 3D CT angiograms is safe, easy to read, and can change to oper- ative plan. The images have a high degree of intraoperative anatomic correlation. We believe this technique can be useful for both the novice and seasoned reconstructive surgeon alike, and deserves further prospective evaluation. Full-color videos of the 3D CT angiograms will be presented.

Preoperative Planning of the Abdominal Perforator Flaps with the Multi-Detector CT Scan (MDCT): 3 Years of Experience Institution where the work was prepared: Sant Pau University Hospital, Bracelona, Spain Jaume Masia, MD, PhD; Sant Pau University Hospital (Universitat Autonoma de Barcelona); J. A. Clavero, MD; Clinica Creu Blanca

Introduction: The key to predict the viability for any muscle perforator flap is an adequate circulation of the chosen perforator. Therefore, a reliable method for the precise identification of the dominant perforator with regard to its position, course and calibre would be extremely valuable. During the last years, the multidetector- row spiral computed tomography has been used as a non-invasive coronary angiography with an excellent results.

Method: Between October 2003 and May 2006 we performed 166 DIEAP flaps for breast reconstruction in 114 female patients. The mean age was 46.7 (range 24-69 years). An preoperative multi-dectector row CT was done in all cases, comparing the results with the preoperative doppler sonography findings and the intra- operative clinical findings.

Results: Comparing the MDCT with the intraoperative findings, no false positive and no false negative results were found, only in one early case we missed a good per- forator when interpreting the MDCT. Comparing the last 50 cases without MDCT and the last 50 cases with MDCT (in which we went directly to the domi- nant perforator), the average operating time saved per patient was 1 hour and 40 minutes.

Conclusion: In conclusion we find that the MDCT is a very useful tool which provides a reliable method for studying the inferior epigastric artery perforators of the lower abdomen. MDCT allows an anatomic study of the donor area, very ease of interpretation not only by the radiologist even by the plastic surgeon. It gives us the possibility to do a virtual anatomy dissection of the patient by the computer because the pictures obtained are 3 dimensional anatomy reconstructions. This technique is well tolerated by patients because is simple and speedy. Therefore it help us in reducing the operating time and the complication rates.

140 A Comparison of Postoperative Sequelae in Free TRAM and DIEP Flaps for Breast Reconstruction Institution where the work was prepared: Memorial Sloan-Kettering Cancer Center, New York, NY, USA Constance M. Chen, MD, MPH; Eric Halvorson; Joseph J. Disa; Babak J. Mehrara; Andrea L. Pusic; Peter G. Cordeiro; Memorial Sloan-Kettering Cancer Center

BACKGROUND: Although the DIEP flap is a major advance in breast reconstruction, many surgeons are reluctant to use it due to concerns about a higher flap loss rate when compared to free TRAM flaps. The DIEP flap involves a more technically challenging dissection and a learning curve associated with perforator selection. This study evaluates our institutional experience with immediate postoperative complications following DIEP and free TRAM flaps.

METHODS: Results of 200 consecutive free TRAM and DIEP breast reconstructions performed at a single institution between 2003 and 2005 were reviewed using a prospec- tively maintained database. The incidence of flap complications following free TRAM and DIEP breast reconstructions was compared. Patient demographics, procedure type, diagnosis, adjuvant treatment, and complications were recorded. Outcome variables included total and partial flap loss, infection, seroma, hematoma, wound healing problems, fat necrosis, and mastectomy flap necrosis.

RESULTS: Two hundred patients were treated with 159 free TRAM flaps (n=159) and 41 DIEP flaps (n=41). No statistically significant differences were seen in mean age, BMI, radiation status, prior lymph node dissection, timing of surgery, smoking history, or systemic disease (p = 0.05). Thoracodorsal anastomoses were more prevalent in the free TRAM group, reflecting a bias in this center's early clinical practice. Fisher's exact test demonstrated significantly more wound healing problems in free TRAMs than in DIEPs (p = 0.01). Patients with wound healing problems exhibited a trend towards obesity (p = 0.07), but no statistically significantly difference in smoking status. Interestingly, despite lower wound healing problems, the DIEP patients also exhibited a trend toward older age, greater BMI, and higher prevalence of cardio- vascular disease. No statistically significant differences were noted for any other complications including total or partial flap loss (Table 1). Table 1. Complications Complication TRAM (Flaps=159) DIEP (Flaps=41) 2-tailed Fisher's exact test Total flap loss 1 (0.6%) 0 n/s Partial flap loss 2 (1.3%) 0 n/s Infection 6 (3.8%) 1 (2.4%) n/s Seroma 12 (7.5%) 2 (4.9%) n/s Hematoma 11 (6.9%) 1 (2.4%)n/s Wound healing problems 21 (13.2%) 0 p = 0.01 Fat Necrosis 20 (12.8%) 5 (12.2%) n/s Mastectomy flap necrosis 24 (15.1%) 6 (14.6%) n/s CONCLUSIONS: In comparing two statistically similar patient populations, we found that the DIEP flap did not result in more postoperative flap-related complications when compared to the free TRAM flap. In the properly selected patient, the DIEP flap is a safe and reliable procedure for breast reconstruction.

A Meta-Analysis of Complication Rates in Free DIEP versus Free TRAM Flaps for Breast Reconstruction Institution where the work was prepared: Div of Plastic Surgery, Hosp of the University of Pennsylvania, Philadelphia, PA, USA Li-Xing Man, MD, MSc; Jesse C. Selber, MD, MPH; Joseph M. Serletti, MD, FACS; University of Pennsylvania

Introduction: Several studies comparing free transverse rectus abdominis myocutaneous (TRAM) flaps to free deep inferior epigastric perforator (DIEP) flaps for breast recon- struction have found no significant differences in flap-related complications and donor-site morbidity. Many of these studies were case series performed at single institutions and may lack the power to demonstrate an effect. The object of this meta-analysis was to develop pooled comparisons of the risk of fat necrosis, partial and total flap loss, abdominal bulge, laxity, or weakness, and abdominal hernia after DIEP and free TRAM surgery.

Methods: A MEDLINE and manual search of English-language articles on DIEP or free TRAM surgery published up to April 2006 yielded 289 citations. Two levels of screening with predefined criteria identified 30 relevant studies.

Results: Six studies reporting both DIEP and TRAM flap outcomes were used to estimate pooled relative risks (RR) of complications and confidence intervals (CIs). A muscle-sparing free TRAM technique was used in three of these studies. There was a 2-fold increase in risk for fat necrosis (RR 1.94; 95% CI 1.28, 2.93) and partial or total flap loss (RR 2.05; 95% CI 1.16, 3.61) in DIEP flap patients compared to those with TRAM flaps. However, there was no difference in the risk for fat necrosis when the analysis was limited to muscle-sparing free TRAM flaps (RR 0.91; 95% CI 0.47, 1.78). Patients receiving DIEP flaps had one-half the risk of developing abdominal bulge or hernia (RR 0.49; 95% CI 0.28, 0.86). This result was not altered when limiting the comparison to muscle-sparing free TRAM flaps. Twelve studies reporting DIEP flap outcomes and 19 studies reporting free TRAM flap outcomes were identified and used to estimate pooled com- plication rates using a random effects model to account for between-study heterogeneity. Pooled flap-related complication rates were similar for free DIEP and TRAM flaps, while donor-site morbidity was higher in the free TRAM flaps.

Summary: The DIEP flap appears to reduce abdominal morbidity but may increase flap-related complications compared to the free TRAM flap.

141 A Comparison of Donor Site Morbidity of the SIEA, DIEP, and ms-TRAM Flaps for Breast Reconstruction Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA Liza C. Wu, MD; Anureet Bajaj; David W. Chang, MD; Pierre Chevray, MD, PhD; University of Texas, MD Anderson Cancer Center

Purpose: Lower abdominal tissue remains the gold standard for autologous tissue breast reconstruction. The TRAM flap harvest technique has evolved to reduce donor site morbidity. This is a comparative study of the donor site function and outcomes of patients who have undergone SIEA flap, DIEP flap, or free ms-TRAM flap breast reconstruction. We investigate the postoperative morbidity and complications and examine patient perceptions of abdominal donor site aesthetics, pain, and function.

Methods: A 12-item questionnaire was sent to elicit patient perceptions regarding donor site aesthetics, pain, and function. A retrospective chart review was used to obtain demographic data and outcomes with regard to donor site complications.

Results: 179 patients during a 5-year period were included in the study. There were 126 unilateral breast reconstruction patients (23 SIEA, 24 DIEP, 79 ms-TRAM), and 53 bilateral reconstruction patients (6 SIEA/SIEA, 5 SIEA/DIEP, 7 SIEA/ms-TRAM, 8 DIEP/DIEP, 4 DIEP/ms-TRAM, 23 ms-TRAM/ms-TRAM). The survey response rate was 63%. There was no difference between responders and non-responders with regard to follow-up, BMI, timing of surgery, flap type, smoking history, or comorbidity. For the patients with a unilateral breast reconstruction, there was no perceived difference between the SIEA vs. DIEP flap patients with regard to abdominal contour, postoperative pain, or abdominal function. There was no difference between the SIEA vs. ms-TRAM flap patients with regard to abdom- inal contour. There was a trend toward SIEA patients having less postoperative pain than ms-TRAM patients. There was a statistically significant difference (p<0.05) between the SIEA vs. ms-TRAM patients with regard to the postoperative ability to lift. In the bilateral reconstructions, there were trends toward patients where one of the two flaps was an SIEA flap having less postoperative pain and better function than patients who had bilateral breast reconstructions with any combination of DIEP and/or ms-TRAM flap. Specifically, there was a statistically significant difference between these two groups with regard to the ability to get out of bed. In total, 2 patients developed hernias and 14 patients developed bulges. No statistical differences was found among the groups with regard to bulge or hernia occurrence.

Conclusions: We conclude that patients who undergo a unilateral SIEA flap have a perceived advantage over patients undergoing ms-TRAM flap with regard to abdominal morbidity. In addition, patients who undergo bilateral breast reconstructions with at least one SIEA flap have less donor site morbidity over patients who have any combination of DIEP and/or ms-TRAM flap.

Timing and Predictors of Arterial and Venous Thrombosis Following Autologous Free TRAM Breast Reconstruction Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA Michel Saint-Cyr, MD; UT Southwestern Medical Center at Dallas; David W. Chang, MD; University of Texas, MD Anderson Cancer Center

Goal: To identify the timing and predictors of both arterial and venous thrombosis following autologous free TRAM flap breast reconstruction. Secondly to deter- mine the salvage rate and salvage procedures performed following both arterial and venous thrombosis.

Materials and Methods: A total of 1698 free TRAM flaps performed for breast reconstructions from 1994 to 2005 at our institution were reviewed. All arterial and venous thrombosis were identified and analyzed for the following predictive factors: flap type, timing of reconstruction, recipient vessels, unilateral vs. bilateral reconstruction, and technical difficulties (friable vessels, small vessels, vessel size mismatch, intimal tear, vessel tension, vessel spasm. Mechanical factors responsible for thrombo- sis (vessel kinking, compression and twisting) as well as the salvage rate and salvage procedures used were investigated. Statistical analysis was performed using a Fishers Exact test, Odds Ratio estimation, and multivariate logistic analysis.

Results: The intra-operative arterial thrombosis rate at the initial surgery was 2.4% versus 0.6% for venous thrombosis. The overall post-operative arterial and venous thrombosis rates were 2.5 % and 1.8% respectively. The flap failure rate was 1.4%. Flap loss was associated with arterial and venous thrombosis in 44% and 57% of cases respectively and with both in 13% of cases. The first arterial and venous thrombosis occurred on average 72H and 71H respectively after the ini- tial surgery. Arterial and venous thrombosis resulting in flap loss occurred on average 75H (3 days) and 102H (4 days) respectively, following the initial surgery. Technical difficulties with the initial anastomosis were encountered in 42% of cases and in 39% of flap losses. Of all factors analyzed, arterial thrombosis and vessel intimal tear were marginally significant (Fisher's p=.05) with OR=5.6 (95% CI 1.05 to 30.05) indicating that intimal tear was predictive of arterial throm- bosis. Vessel twisting was a significant predictor of venous thrombosis (Fisher's p=.04). There was also significant relationship between arterial thrombosis and small artery size (Fishers p=.02). The flap salvage rates following arterial and venous thrombosis were 51.2% and 42% respectively. The arterial and venous con- version rates were 9.5% and 8.1% respectively when flap salvage was attempted. Other attempts at salvaged included; heparine 41%, streptokinase 19%, vein grafting 11%, and thrombectomy 5.4%.

Conclusion: Although TRAM flap failure rates in breast reconstruction remain relatively low careful flap monitoring is warranted up to 4 days post-operatively. Almost half of all anastomotic thrombosis and flap failures can be related to mechanical or technical problems at the initial surgery.

142 The SIEA Flap Revisited: New and Improved Techniques Institution where the work was prepared: The Methodist Hospital, Houston, TX, USA Aldona J. Spiegel, MD; Farah Naz Khan, MD; The Methodist Hospital

Background: Although the superficial inferior epigastric artery (SIEA) flap was first described for breast reconstruction by Grotting in 1991, few authors have subsequently reported its dissection or use. The purpose of our study is to provide a detailed explanation of the evolution of our dissection and harvesting techniques.

Patients and Methods: All 83 patients who underwent 100 SIEA flaps for breast reconstruction are included in this study. The pre-operative and intra-operative records for these patients were reviewed with respect to flap design, the external diameter of the SIE and internal mammary vessels, the use of contralateral versus ipsilateral vessels, and the percentage of flap used (for a unilateral reconstruction).

Results: To increase flap reliability, we changed our algorithm midway through our series so that the SIEA flap was only harvested if the external diameter of the SIEA at the lower abdominal incision was larger than or equal to 1.5 mm. The average SIEA external diameter in nonthrombotic vessels was 1.8 mm. The average IMA diameter in the third intercostal space was 2.14 mm. Of the 52 unilateral reconstructions performed, 18 were done using ipsilateral vessels and 34 were done with contralateral vessels. In 40 of those unilateral reconstructions, the average percentage of total flap used after excision of zone IV and any other ischemic tissue was 66.5%.

Discussion: We have found that because of the anatomic variability inherent to the SIEA flap, several important points need to be addressed: (1) To help ensure flap reli- ability, we believe it is necessary for the SIEA to have an external diameter larger than or equal to 1.5 mm at the level of the lower abdominal incision. This allows for minimal size mismatch with the IMA in the third intercostal space. (2) It is possible to safely harvest tissue across the midline as long as zone IV and any ischemic looking tissue is excised prior to flap inset. (3) We prefer to use the ipsilateral flap, when possible, because it allows for better inset and shaping. (4) To reduce the rate of donor-site seroma formation, it is best to skeletonize the SIE vessels down to their origin and to leave the lymphatics intact. (5) We recommend use of the venae comitantes for the anastomosis with the IMV because sufficient length is available. The SIEV can be kept as a lifeboat in cases of venous congestion where it can be used for a second anastomosis.

A Head to Head Comparison of the SIEA Flap and the Muscle Sparing Free TRAM: Is the Rate of Flap Loss Worth the Gain in Abdominal Wall Function? Institution where the work was prepared: University of Pennsylvania, Philadelphia, PA, USA Jesse Creed Selber, MD, MPH1; Stephen J. Vega, MD2; Seema Sonnad1; Joseph Serletti3; (1)University of Pennsylvania, (2)Strong-Memorial Hospital, The University of Rochester Medical Center, (3)Division of Plastic Surgery

As evidence increasingly indicates a relatively small functional difference in abdominal wall donor site morbidity between the muscle sparing free TRAM and the DIEP flap, microsurgeons continue to search for the “perfect flap” with respect to both reliability and donor site morbidity. The SIEA flap is a candidate for such a monicher. In this study the authors compare the SIEA to the muscle sparing free TRAM across a spectrum of clinical outcomes to determine whether gains in abdominal wall function are off-set by a higher complication rate.

Methods: Forty-six consecutive SIEA flaps in 39 patients are compared to 569 consecutive free TRAMs in 500 patients. A database was compiled prospectively. Chi square and Fisher's Exact tests were used to determine significant differences in preoperative risk factors as well as complications in the two groups.

Results: There was no significant difference in age, past medical history, history of smoking , BMI, immediate versus delayed, length of follow-up or recipient vessels between the two groups. Outcomes included rate of intraoperative and post operative arterial and venous thrombosis, reoperation, abdominal hernia, seroma, hematoma, fat necrosis, delayed wound healing, infection, partial flap loss, and total flap loss. In the SIEA group, there was 1 instance total flap loss (2.2%) and no clinically relevant abdominal morbidity. In the free TRAM group, there were two total flap losses (.2%), and a hernia rate of 1.9%. There was a higher incidence of intraoperative and post-operative vessel thrombosis requiring anastomotic revision in the SIEA group (13%) compared to the free TRAM group (5.6%).

Conclusion: The SIEA flap has the clear advantage of leaving the abdominal wall completely unviolated. It has the clear disadvantagge of a substantially higher rate of thrombotic complications, although the flap success rate remains high. Because of these thrombotic complications, the SIEA flap should be limited to non- smokers, moderate obesity, patients unlikely to require postoperative radiation, and breast reconstruction volumes requiring only half of the typical skin island. In addition, the SIEA flap should be performed by those experienced in the management of intraoperative and postoperative thrombosis. For all other clinical situations, the free TRAM flap remains the flap of choice for dependable results and limited donor site morbidity.

143 Blood Supply of Abdominal flaps for Breast Reconstruction Institution where the work was prepared: University Hospitals, Leuven, Belgium Marc Vandevoort, MD; Pieter Vermeulen; Gerd Fabre; Jan Jeroen Vranckx; University Hospital Gasthuisberg

INTRODUCTION: In contrast to conventional flaps like latissimus dorsi, gracilis and many other well described flaps for reconstructive surgery, DIEP and SIEA flaps do not have a consistent predominant feeding pedicle that contains an artery and at least one concommitant vein. This means that it is not unusual that an extra feeding artery or draining vein is needed to guarantee vascularisation of the entire flap. Preoperatively it will never be perfectly clear that this particular flap can be harvested on that particular pedicle. Doppler ultrasound and more recently MD CT scanning has been advocated to localise the best perforator or the size and localisation of the superficial epigastric vessels, but often it has to be decided intraoperatively when additional blood supply is needed.

MATERIAL AND METHODS: We looked at the vascular supply of 462 DIEP and 100 SIEA flaps and whether additional arteries and/or veins were needed. Preoperative duplex doppler exam- ination was obtained to localise and measure perforators and superficial epigastric vessels. During the operation the decision of adding vascular anastomoses was made according to intraoperative visual quality of the flaps.

RESULTS: In the DIEP group 32 of 462 flaps (6,9%) needed additional blood supply. There were 4 flaps with a combined arterial and venous “intra-flapanastomosis” and 28 flaps with an additional venous anastomosis. Of these flaps with an extra anastomsed vessel, there were no flap failures; partial flap failure occured in 1/32 cases (zone 4) and fat necrosis in another 1/32. In the SIEA group, 6 out of 100 flaps (6%) received additional drainage. All 6 flaps needed an extra venous drainage in order to be well perfused and drained. In those 6 flaps no flap necrosis, no partial flap necrosis nor fat necrosis was noticed. Different options for the additional blood supply were committant veins, contralateral perforators and other recipient vessels. In these series there is certainly a trend towards more additional anastomotic solutions.

CONCLUSIONS Although becoming the gold standard in autologous breast reconstruction there still is no flap with a standard blood supply. Very often, additional flap ves- sels are plugged in different vascular options and the decision making is still to be done during the operative procedure itself. The incidence of extra anasto- moses is becoming higher as more experience in this type of flap reconstruction is gained. Untill now, there is no preoperative way of investigation to predict whether additional vascular supply is needed.

Outcome after Revision of Autologous Breast Reconstruction with Microvascular Free DIEP, SIEA and SGAP Flap Institution where the work was prepared: UZ Leuven Gasthuisberg, Leuven, Belgium Pieter Vermeulen, MD; Marc Vandevoort; Gerd Fabre; Jan Jeroen Vranckx; University Hospital Gasthuisberg

BACKGROUND During the past decade, Adipocutaneous Free Flaps have become a tempting choice for autologous breast reconstruction. This procedure favours a superior clinical and aesthetic outcome. However, the ultimate fate of the flap when revision for microvascular thrombosis is necessary, is still a matter of debate. We review our experience in flap revision and outcome in Deep Inferior Epigastric Perforator (DIEP), Superficial Inferior Epigastric Artery (SIEA) and Superior Gluteal Artery Perforator (SGAP) flaps for breast reconstruction.

PATIENTS From august 1997 to december 2005, 462 DIEPs, 100 SIEAs and 51 SGAPs were performed. There were 94 bilateral reconstructions. Patients needing bilater- al SGAPs were operated in 2 sessions. Average age was 48 years, BMI, 24.6. Postoperatively, flaps were monitored clinically and with doppler ultrasound each 2 hours.

RESULTS Overall revision rate for microvascular thrombosis was 2.9% and overall flap failure rate was 1.8%. However, there were large differences between the different flaps. Revision rate was 1.5% in DIEPs, 6% in SIEAs and 9.8% in SGAPs. Ultimate failure rate was 0.86% in DIEPs, 5% in SIEAs and 3.4% in SGAPs. Average time before first revision was overall 66.3 hours. Time to revision was not correlated to ultimate flap failure. Rivision of SIEA flaps was performed later (avg. 73.2 hours; p=0.2) due to subclinical arterial ischemia in all cases. Of all revised flaps, 61% (11/18) eventually had to be removed and of the 7 salvaged flaps 2 (28.5%) developed fat necrosis. A second revision was necessary in 3 cases and all these flaps eventually failed.

CONCLUSIONS No risk factors defining flap outcome after revision could be defined in this study. Only 5 of 18 (29%) of revised flaps had a favorable clinical outcome. In this series, the SIEA flap showed a high revision rate. All SIEA-occlusions were primary arterial and only 1 in 6 revised flaps could be salvaged. The SGAP was found to be a difficult but robust flap as reflected in its higher revision rate compared to DIEP, but fair clinical outcome with no fat necrosis. Time span between procedure and revision didn't seem to affect the outcome.

144 Double-Pedicle Abdominal Perforator Free Flaps for Unilateral Breast Reconstruction Institution where the work was prepared: Gent University Hospital – Plastic and Reconstruction Department, Gent, Belgium Moustapha Hamdi, MD; Dana K. Khuthaila, MD; Koenraad Van Landuyt, MD; Nathalie Roche, MD; Stan Monstrey, MD, PhD; Gent University Hospital

Background: The DIEAP (deep inferior epigastric artery perforator) flap is a suitable option for breast reconstruction resulting in a high aesthetic outcome, and minimal donor site morbidity. However it may be considered a contraindication in cases of lack of tissue or abdominal . The purpose of this paper is to discuss options of using abdominal perforator flaps, based on double – Pedicle techniques, despite the contraindications. Material &

Methods: Abdominal skin double-pedicle free flaps were necessary in 16 patients requesting unilateral breast reconstruction. The indications were multiple abdominal scars, liposuction and thin patients in 5, 3, and 8 cases respectively. Preoperative mapping of the vascular network was done using Duplex and / or multi- detector CT scan imaging.

Results: Different microsurgical techniques were performed to provide enough blood supply to the requested flaps: Perforator (P) to contralateral Deep Inferior Epigastric (DIE) anastomosis (P/DIEAP), in 2 patients; bilateral DIE vessels (DIEAP/DIEAP) in 7 patients; and DIE with SIE (superficial inferior epigastric) vessels in 7 patients (DIEAP/SIEA). One pedicle was always anastomosed to the internal mammary vessels. The second pedicle was anastomosed end-to-end to a side branch of the DIE or end-to-side with the DIE pedicle in 13 cases. The thoracodorsal vessels were used as recipient vessels for the second pedicle in three cases. Average oper- ative time was 6 h and 30 min (range 5 h 30 min - 8 h). All sixteen flaps survived and fat necrosis occurred in one case.

Conclusion: The harvesting of perforator free flaps may be contraindicated in some patients however they are still a feasible option as long as the vessels to the skin are present. Preoperative planning combined with high expertise in microsurgical techniques are the key points in the high success rate in these difficult cases.

The Sensational Breast Reconstruction: Innervated versus Non-Innervated Flaps Institution where the work was prepared: The Methodist Hospital, Houston, TX, USA Aldona J. Spiegel, MD1; Farah Naz Khan, MD1; Michael Charles Edwards, MD/PhD2; Joe P. Day, PhD2; (1)The Methodist Hospital, (2)Center for Plastic, Reconstructive, Cosmetic, and Peripheral Nerve Surgery

Background: Although the goal of breast reconstruction is to restore form and function, restoration of sensation is often overlooked. Studies have shown that spontaneous recovery of sensation does occur in reconstructed breasts but it is quite sporadic and varies from patient to patient. The purpose of this study was to compare sensory recovery in innervated versus non-innervated breasts reconstructed with either the superficial inferior epigastric artery (SIEA) flap or deep inferior epi- gastric perforator (DIEP) flap.

Patients and Methods: 12 patients were included in the study. 6 patients had innervated SIEA or DIEP flaps and 6 patients had non-innervated SIEA or DIEP flaps. Each sensate patient was matched with a non-sensate patient in terms of age, BMI, and length of follow-up. Sensitivity to fine touch was assessed in the reconstructed and non-reconstructed breast with a pressure sensing device for 1 point static and 2 point static discrimination. Testing was performed in a radial pattern, from the periphery of the breast to the center. 5 readings were obtained at each point and averaged to obtain a value for the point. Maps were developed illustrat- ing the various pressures in different areas of the breast. A questionnaire was also given to the patients for a subjective evaluation of the return of sensation.

Results: Of the 6 innervated flaps, 4 were SIEA flaps and 2 were DIEP flaps. Of the 6 non-innervated flaps, 5 were SIEA flaps and 1 was a DIEP flap. 7 flaps were imme- diate reconstructions and 5 were delayed. Innervated flaps required 2 to 5 times as much pressure for 1 point static testing as the normal breast. Non-inner- vated flaps required 5 to 20 times as much pressure for 1 point static testing as the normal breast. Both delayed and immediate innervated flaps required less absolute pressure (Gm/mm2) in the center of the flap for 1 point static testing as compared to the non-innervated flaps. All innervated flap patients had 2 point discrimination but the return of 2 point discrimination in non-innervated flaps was variable.

Conclusions: The return of sensation in innervated breasts was much better than the return of sensation in non-innervated breasts. Furthermore, innervated flaps were much more sensitive in the center of the flap, in the area of the original nerve anastomosis.

145 The Semi-Lunar Transverse Inner Thigh Flap for Microvascular Breast Reconstruction: An Excellent Alternative to Abdominal Flaps Institution where the work was prepared: California Pacific Medical Center, San Francisco, CA, USA Rudolf F. Buntic, MD1; Darrell Brooks, MD2; Karen M. Horton, MD, MSc2; (1)The Buncke Clinic, (2)Buncke Clinic

In many patients with previous abdominoplasty or inadequate abdominal tissue, the inner thigh flap can be used to reconstruct small and medium breasts. We used a semi-lunar inner thigh flap based on the transverse upper gracilis (TUG) anatomy for breast reconstruction. Shape and projection make this flap an excellent choice in selected patients requiring breast reconstruction. The procedure can be combined with immediate nipple areola reconstruction.

Methods Between 2004 and 2006, 9 TUG flap reconstruction in 6 patients were performed. Two patients had previous abdominoplasty and failed implant reconstruc- tion. One patient had inadequate abdominal donor tissue; one patient had previous DIEP reconstruction with significant fat necrosis. Two patients elected to undergo TUG flap reconstruction in lieu of abdominal tissue reconstruction. All flaps were vascularized through the internal mammary system.

The flap is harvested with a transverse skin paddle on the medial thigh, with a semi-lunar design. Markings and harvest will be outlined in detail. The flap was shaped folding with the semi-lunar tips approximated and the apex of the central fold used as the area of maximal projection. This area could be plicated for immediate nipple reconstruction. The gracilis muscle was used to augment lower pole fullness.

Results The patient age ranged from 42 to 60 years old and all patients had a history of breast cancer. Five breasts were reconstructed in the face of previous radia- tion. All flaps survived. One patient had to be taken back to the operating room 12 hours after reconstruction because of a venous thrombosis. This was repaired and the flap survived without any flap loss or fat necrosis. There were no cases of skin necrosis, fat necrosis, flap loss. Patient satisfaction has been uniformly excellent.

Discussion Although other autologous tissue reconstruction options are available to patients that have had previous abdominoplasty and in very thin patients, in many of these patients, the tranverse upper gracilis (TUG) flap can be used to reconstruct small and medium sized breasts. It provides a well vascularized and shapely reconstruction. Unlike loss of the the rectus muscle, loss of the gracilis muscle does not result in any significant increase in hernias or significant donor com- plications. The gracilis muscle pedicle and harvest are extremely reliable and straight forward. No intraoperative repositioning is required as in the case of gluteal flaps, and the pedicle is of excellent quality. The donor thigh lift is and added aesthetic perk of the procedure.

Congenital Breast Deformity Reconstruction using Perforator Flaps Institution where the work was prepared: Louisiana State University Medical School, New Orleans, LA, USA Abhinav K. Gautam, BS; Timothy S. Mountcastle; Joshua L. Levine; Robert J. Allen; Ernest S. Chiu; LSU Health Sciences Center

Background: Congenital breast deformities such as Poland's Syndrome, unilateral congenital hypoplasia, tuberous breast anomaly, and amastia pose a challenging plastic surgical dilemma. The majority of patients are young, healthy individuals who seek aesthetic restoration of their breast deformities. Currently, both implant and autologous reconstructive techniques are utilized. This study focuses on our experience with congenital breast deformity patients who underwent reconstruc- tion using a perforator flap.

Methods: From 1994 to 2005, a retrospective chart review was performed on women who underwent breast reconstruction using perforator flaps to correct congenital breast deformities and asymmetry. Patient age, breast deformity type, perforator flap type, flap volume, recipient vessels, postoperative complications, revisions, and aesthetic results were determined.

Results: Over an eleven year period, 12 perforator flaps were performed. All cases were for unilateral breast deformities. The patients ranged from 16 to 43 years of age. 6 patients had undergone previous correctional surgeries. Eight (n=8) flaps were used for correction of Poland's syndrome and its associated chest wall defor- mities. Four (n=4) flaps were used for correction of unilateral breast hypoplasia. In all cases, the internal mammary vessels were the recipient vessels of choice. No flaps were lost. No vein grafts were used. All patients were discharged on the fourth post-operative day. Complications encountered included seroma, hematoma, and nipple malposition. Revisional surgery was performed in 30% of the cases. Aesthetic results varied from poor to excellent.

Conclusions: Perforator flaps are an acceptable choice for patients with congenital breast deformities seeking autologous breast reconstruction. DIEP or SIEA flaps are per- formed when adequate abdominal tissue is available; however, many young patients have inadequate abdominal tissue, thus a GAP flap can be utilized. Perforator flaps are a safe, reliable surgical technique. In the properly selected patient, donor site morbidity and functional compromise is minimized, improved self esteem is noted, postoperative pain is decreased, and excellent long-term aesthetic results can be achieved.

146 ASRM Concurrent Scientific Paper Presentations A-2

Replantation in Developing Countries Institution where the work was prepared: SOS Mano Santo Domingo, Hand group, Santo Domingo, Dominican Republic Hector Herrand, MD; Marcos Nuñez, MD; Otoniel Diaz, MD; SOS Mano Santo Domingo

From January 1995 to January 2006 we have done 42 hands replantation including one bilateral case, in Santo Domingo, Dominican Republic, by our group SOS Mano Santo Domingo. Males were involved in 95% of the cases. Age ranges from 10 years to 59 years with and average of 26 years.The most common mechanism of action was agression 38/41 (93%), and machete was the instrument used during the agression in all cases.36 patients were right hand domi- nant and the majority of cases involved the non dominant hand. The most common amputation level was the Radiocarpal area with 22 cases (52%).Most of patients (19/41) 46% arrived between 4 and 6 hours after the trauma. 16 hands were correctly preserved and 26 hands were incorrectly transported under cold or warm ischemia. Our local temperature range from 29 to 32 centigrades. Operative time range from 6 hours to 13 hours, average 9.36 hours. All cases were done under loupes magnification (3.5X and 4.5X). Only one case was fixed with plates and screws the others were done with pins and wires. Residents partic- ipate very actively in most of the cases. We have 2 important complications associated to postop bleeding, one case developed a transitory acute renal failure that require dialysis. 12 cases developed vascular insufficiency, one of them could be solved and the hand survived. 31 hands (74%) do succesfully and we lost 11 hands (26%). 23 patients showed good or excellent results, 8 patients did regularly or poorly (4 and 4) when we compared return to daily activities, ROM, and 2PD static. The maximum follow up is 10 years and the minimal 4 months. Only 20 patients have been followed by personal contact during at least one year. We performed this 41 patients in 7 different institutions: 3 public, 1 semiprivate and 4 private. We calculate an average of 2,600 dollars in hospitaliza- tion and OR expenses per patient, and we only have charged private fees in only 5 patients with an income average of 1,394 dollars per patient. In the pub- lic hospital we have only the payment of the monthly salary equivalent to 606 dollars.

Reconstruction of Congenital Differences of the Hand Using Microsurgical Toe Transfers Institution where the work was prepared: University of California, Los Angeles, Los Angeles, CA, USA Neil F. Jones, MD; University Of California Los Angeles Introduction: A large series of children with congenital differences of the hand was analyzed retrospectively to develop a more simplified classification system for congeni- tal absence of the digits and to develop an algorithm which directly predicts which microsurgical toe-to-hand transfers will provide the best hand function.

Materials and Methods: 78 toe transfers have been performed in 65 children for congenital anomalies of the hand, classified by the Swanson system as transverse deficiencies or symbrachydacty- ly (32); radial longitudinal deficiencies (5); cleft hand (9) and congenital constriction ring syndrome (17). Preoperative X-rays and photographs were analyzed to deter- mine which rays were missing and their level of absence. A new classification system was developed to describe nine phenotypes of congenital absence of the digits.

Results: Optimal reconstruction of the severe radial deficiency phenotypes involving the thumb, index and middle fingers is a toe-to-thumb transfer using either the second toe (21) or great toe (14). For severe transverse deficiencies involving all four fingers, there are two options - either a single second toe transfer into the ring or small fin- ger position (25); or bilateral second toes transferred either simultaneously or in sequential procedures into the middle finger and small finger positions to provide three point pinch (5). The aplastic hand with absence of all five digits is best reconstructed with bilateral second toe transfers into the thumb and small finger positions (6). Six toe transfers required re-exploration of the microsurgical anastomoses for a re-exploration rate of 7.7%. Two toe transfer failed for a success rate of 97.5%. All the children have regained sensation in the transferred toes and improvement in hand function.

Discussion: Retrospective analysis of a large series of children with congenital anomalies of the hand has resulted in the development of a simplified classification system and a treatment algorithm, which directly predicts which of four possible microsurgical toe-to-hand transfers will provide the most optimal reconstruction of severe transverse and longitudinal deficiencies of the hand.

Simultaneous Double Second Toe Transplantation for Reconstruction of Multiple Digit Loss in Traumatic Hand Injuries Institution where the work was prepared: The Buncke clinic and Division of Microsurgery, CPMC, San Francisco, CA, USA Fernando A. Herrera Jr, MD; Alfonso Camberos, MD; Jacob J. Freiman; Charles K. Lee; Rudy Buntic; Gregory M. Buncke; California Pacific Medical Center Purpose: To review our recent 10-year experience of simultaneous double second toe transplants for reconstruction of traumatic injuries following multiple digit loss.

Methods: Retrospective chart review of 11 cases of traumatic hand injuries resulting in multi-digit loss of the index, long, ring, or small fingers (excluding the thumb) that underwent simultaneous double second toe transplantation for digital reconstruction.

Results: From 1995 to 2005, 11 patients underwent a simultaneous double second toe transplantation. Mean age was 36 years (range 6 to 60 years); all patients were male, all were right hand dominant. Index and long fingers were reconstructed in 3 patients, long and ring finger in 7 patients, and ring and small finger in 1 patient. All patients had undergone completion amputation after mutilating crush/avulsion injuries obviating replantation. A simultaneous 3-Team approach was used in all cases. The average operating time was 9 hrs (Range 7-15hrs). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months). Complications included microvascular venous thrombosis, loss of the transplanted toe, bleeding, and infection. All donor sites were closed primarily and there was minimal donor-site morbidity. 21/22 (95%) toe transplants survived. Secondary surgery was performed in 10/11 patients, including tenolysis, flap debulking, and skin grafting. Average moving-2 point discrimination was 5mm in each digit after 7 month follow-up. Mean grip strength approached 50% of the contralateral hand. Mean time to work return after digital reconstruction was 10 months. 8/11 of the patients returned to work after vocational rehabilitation.

Conclusion: Simultaneous double second toe transplantation is a viable and efficient procedure for multi-digit reconstruction. The 3-Team approach allows for a single stage reconstruction to a multi-level problem. Functional and aesthetic improvement to the hand can be significant with minimal donor site morbidity to the feet.

147 Functional Assessment of the Reconstructed Fingertips after Free Toe Pulp Transfer Institution where the work was prepared: Cheng-Hung Lin, Taipei, Taiwan Cheng-Hung Lin, MD; Chih-Hung Lin; Yu-Te Lin; Paolo Sassu; Fu-Chan Wei; Chang Gung Memorial Hospital, Chang Gung University

Background: Posttraumatic fingertip reconstruction with a free toe pulp was first described in 1979. Although there have been several studies regarding the sensibility assess- ment of the reconstructed digits, only two-point discrimination (2PD) test was usually employed and the case numbers were limited. The goal of this study was to comprehensively assess the functional outcome of the reconstructed fingertips after free toe pulp transfer.

Methods: There were 15 flaps in 14 male patients recruited in this retrospective study. Objective sensory recovery was assessed with 2PD and Semmes-Weinstein monofil- ament (SWM) tests. Pinch power of the reconstructed digits as well as subjective pain and discomfort was also evaluated. Statistical analysis was used to com- pare and investigate the relationship of the results.

Results: According to the findings of 2PD test, 6 flaps obtained good results, 6 flaps gained fair results, and 3 flaps could perceive only one point. The SWM test revealed diminished light touch in 6 flaps, diminished protective sensation in 8 flaps and loss of protective sensation in one flap. Strong correlation between s2PD and m2PD (?=0.78747, p=0.0005), but weak correlation between s2PD and SWM of the flaps (?=0.34240, p=0.2116) was found. There was significant difference in s2PD (p<0.01), but no significant difference in SWM between the contralateral toes and flaps. The mean percentage difference of pinch power between the dominant and non-dominant hand was 6.72% with involvement of the dominant hands and 34.16% with involvement of the non-dominant hands. There was no significant difference between the pinch power of the reconstructed digits and theoretical values. Cold intolerance and weather ache was observed in 3 patients and hyperesthesia was reported by one patient. Conclusion: After free toe pulp transfer, the reconstructed digits could obtain equal sen- sory threshold as the donor toes, but the functional sensibility results depending on daily use of the digits and sensory reeducation were varied. Pinch power of the traumatized digits could be restored after reconstruction. Free toe pulp transfer could restore the sensibility, stability and durability of the finger pulp, and achieved functional recovery of the traumatized digits.

Osteoplastic Thumb Ray Restoration with Secondary Toe Transfer for Opposable Basic Hand Reconstruction Institution where the work was prepared: Chang Gung Memorial Hospital, Taoyuan county, Taiwan Chih-Hung Lin; Yu-Te Lin; Yu-Te Lin; Cheng-Hung Lin; Cheng-Hung Lin; Samir Mardini; Fu-Chan Wei; Chang Gung University

Purpose: A mutilating hand injury might present an extensive bone and soft tissue defect that requires a flap for coverage. Both pedicled groin flap and free flap with accompanying vascularized iliac crest can provide composite tissues for thumb ray restoration either as a temporary or definite reconstruction. Materials and

Methods: Twenty-two hand mutilating injuries with thumbs amputated proximal to metacarpophalangeal joint level, with or without finger amputations, underwent osteo- plastic surgeries for first ray composite bone and soft tissue defect reconstruction in emergency or acute surgeries. Subsequently, ten patients received microvas- cular transfer of toe flaps (8 great toes to thumb, and 3 combined 2nd and 3rd toes, and one 2nd toe to finger defects for the purpose of opposable basic hand function reconstruction. The Kapandji classification was used for the evaluation of opposition function after osteoplastic surgery and after toe transfer.

Results: The morbidities of the various osteoplastic surgeries included a pseudojoint, skin flap ulceration, one distal flap loss, and a groin flap failure. Eleven of the osteoplastic neo-thumb (11/22, 50%) achieved opposable functionally basic hand. After a corrective osteotomy on the iliac crest, 13 patients achieved basic hand function (13/22, 59.1%). Among the cased of 13 thumb amputation only, 11 osteoplastic neo- thumb can accomplish opposition (11/13, 90.8%). All 12 secondary toes transfers ran uneventful course without re-exploration. With the incorporation of toe transfer for the thumb and/or fingers, the accomplish rate of opposable basic hand function can be promoted up to 72.7% (16/22). Conclusion: The reconstructive procedures for mutilated hand should be individual- ized. Osteoplastic neo-thumb can provide either a definite basic hand function or a preparation for secondary toe transfer. The subsequent toe transfer can improve the outcomes of a mutilated hand to be an opposable hand.

Metacarpal Bone Missing in Childhood: Reconstruction by Free Vascularized Iliac Bone Graft Including its Cartilage for Bone Growth Consideration Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, Taiwan Chao-yi Lai; Chang Gung Memorial Hospital, Chang Gung University

Introduction: Severe crush injury to hand may lead metacarpal bones even carpal bones lost and reconstruction for this injury especially in growing children was a great chal- lenge on shape, function and growth concern. From the medline resort, we found that vascularized iliac bone graft was mostly used in femoral head necrosis, mandibular defect, tibia osteomyelitis and scaphoid or lunate reconstruction whether by free or pedicle bone flap methods. There was no study mentioned about metacarpal bones missing reconstructed by free vascularized iliac bone graft. We here report our experience in 2 cases. Cases report Case 1: A 7 y/o girl was a vic- tim of compression and contact burn of right hand with 2nd to 5th metacarpal bone loss; Before she went to our clinics, she received free Latissimus dorsi mus- cle flap and STSG for wound coverage in other hospital. We performed free iliac osteocutaneous flap including its cartilage crest for bone, cartilage and skin replace- ment. After 5 years follow-up, it showed growth of the transferred iliac bone and acceptable results in shape and function Case 2: A 7 y/o boy was a case of right hand Crushing injury with traumatic absence of whole right 4th and 5th metacarpal bones and almost all carpal bones. Pedicle groin flap for wound coverage and tendon grafts from Tensor fascia lata for right EPL and EDC repair were done in two stages. We performed free iliac osteocutaneous flap for carpal and metacarpal bones replacement. After 3 years f/u, it showed acceptable result in shape and function. We also found that the bone graft keep growing simultaneously.

Conclusion: Free vascularized iliac bone graft is a suitable choice for child patient with missing metacarpal and carpal bones reconstruction.

148 Our Experience with Proximal Free Fibular Head Flap for Articular Reconstructions Institution where the work was prepared: The Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel Arik Zaretski, MD1; Aharon Amir1; David Leshem1; Yoav Barnea1; Jerry Weiss1; Yehuda Kollender, MD2; Jacob Bickels2; Izzac Meller2; Eyal Gur1; (1)Sackler Faculty of Medicine, Tel-Aviv University, (2)The Tel-Aviv Sourasky Medical Center Introduction: Endoprosthetic reconstruction is considered the mainstay of limb salvage in periarticular bone tumors. However, this procedure has limited durability especially when preformed in children and young adults. The fibula is suitable for hemiartheroplasty procedure since it can be harvested including the proximal articular surface.

Patients and Methods: Between 2000 and 2005 five patients underwent hemiartheroplasty procedures using the free fibular head flap. There where 3 males and 2 females, the mean age was 14 years (3.5 – 42). Four patients where operated for malignant bone tumors and one for chronic osteomyelitis of the distal humerus. In two patients the fibula was used for distal radius and wrist joint reconstruction, in two for distal humerus and elbow joint in one it was used for proximal femur and hip joint reconstruction. The peroneal vessels were used as donor vessels in 2 patients. When a viable growth plate was included the lateral genicular vessels or the anterior tibial vessels where included.

Results: In all patients a Technetium MDP bone scan with SPECT confirmed flap viability 10 days after surgery. Union documented by X-ray imaging after average of 5 months after surgery. We had no major or minor post operative complications. Functional assessments were preformed using the American Musculoskeletal Tumor Society (AMSTS, Enneking's classification) and will be detailed for each case. Follow-up period is 1- 5 years.

Conclusions: We found hemiartheroplasty procedure using the free fibular flap with its proximal head a safe procedure with good functional results. The head of the fibu- la resembles the articular surfaces of the radius and distal humerus but has a different structure compared to the proximal femur. We found that the head of the fibula has the potential of re-adjusting and reshaping itself according to the opposite joint surface. It is striking to see the fibular neo-articular surface looking similar to the original bones that were resected. Although there is some concern regarding donor site morbidity when the fibular head is included in the flap we did not find increased morbidity. Our basic principal is to prefer a biological reconstructions rather than the use of endoprosthesis or allograft due to the longer durability over the others. Now when we are aware that the fibula flap provides durability as well as near normal motion and growth potential, we believe that it will become the gold standard for biological articular reconstruction, in the future.

Radial Nerve Palsy: Classification, Treatment and Result- 300 Cases Study Institution where the work was prepared: Chang Gung Memorial Hospital, Taipei, Taiwan Chun-Hao Pan; David, Chwei-Chin Chuang; Chang Gung Memorial Hospital Purpose The goal of this study was to review the outcomes of surgical management in patients with radial nerve palsy treated by single senior surgeon (DCC Chuang) at Chang Gung Memorial Hospital over a period of 20 years.

Material & Methods Three hundred and seven patients with radial nerve palsy were treated and evaluated. The most common mechanism of radial nerve injury was fracture of humerus, few by laceration and blunt contusion. The classification based on the level of radial nerve injury: Group A- infraclavicular area (brachial plexus not included); Group B- radial sulcus area; Group C- radial sulcus to posterior interosseous nerve area; Group D- posterior interosseous nerve area. Primary neurorraphy, neurol- ysis or nerve grafting were performed in all patients. Evaluation of surgical outcomes was based on the Medical Research Council classification for motor recovery. The definition of success rate is not less than M3. Factors affecting surgical outcomes, such as age of the patient, denervation time, length of the nerve graft, and level of the injury were evaluated.

Result The overall success rate of our study was 85%. The significant factors of good outcome included: denervation time (3-4 months) and length of the nerve graft (less than 6cm). Delayed exploration was recommended for humerus fracture related radial nerve palsy. Exploration and immediate tendon transfer were suggested in group B. The success rate of group D was the highest. Our study provided a new classification system and treatment algorithm for management of patients with radial

Restoration of Axillary Nerve Function by Neurotization from the Radial Nerve: Our Early Experience Institution where the work was prepared: Duke Unversity Medical Center, Durham, NC, USA Julian McClees Aldridge III, MD; James A. Nunley; Duke University Purpose: To describe our experience with transferring a branch of the radial nerve to the axillary nerve in the setting of either isolated axillary nerve injury or an upper brachial plexopathy for restoration of deltoid function. Our institutional review board judgement on our project is pending and when approved we plan to retrospectively review the charts of our patients who were treated for either isolated axillary nerve palsy or traumatic upper brachial plexopathy with either incomplete (M1 or M2 grade)or no return M0) of deltoid func- tion. All surgeries were performed as outpatient procedures by one or both of the authors. Through a single posterior shoulder incision, all nerve transfers were completed with the use of an operative microscope.

Results: **awaiting IRB approval to review and submit results. We have been told approval should be forthright. We will update this submission at that time. Conclusions: We feel this is a safe and effective option in addressing the often difficult clinical scenario of deltoid paralysis following an isolated axillary nerve palsy or a C5-6 brachial plexus injury. Furthermore, this nerve transfer can be done with relative ease as an outpatient procedure, through a single posterior shoulder incision. Key words: Nerve Transfer, Brachial Plexus, Axillary Nerve, Deltoid

149 Prevention of First Web Retraction in Traumatic Cases with Emergency Buried Free Flaps Institution where the work was prepared: Clinica Aston, Valencia, Spain Pedro C. Cavadas, MD, PhD; Clinica Aston

Background: Crush injuries to the hand often result in hydraulic extrusion of the muscles of the first web. This injury, although deceivingly benign is a high-energy injury, since extreme- ly high instant hydraulic pressure is needed for the skin to break and allow muscle extrusion. If untreated, it leads to severe adduction retraction of the first metacarpal.

Material and Methods: 15 cases of crush injury to the first web with hydraulic extrusion of the muscles (adductor pollicis and 1st dorsal interosseous) were treated in 14 patients. The muscles of the first web were radically debrided and a free flap was transferred to fill the dead space within the web as an emergency. The flaps used were 5 segmental distal gracilis, three segmental distal sartorious, four saphenous subcutaneous flaps and three subcutaneous lateral arm flaps.

Results: all 15 flaps were viable. The 1st web remained soft and fully mobile without adduction retraction. Thirteen patients returned to their previous employment.

Conclusion: muscle debridement and filling of the first web with a free flap in an emergency basis is effective in preventing adduction retraction in crush injuries with hydraulic muscle extrusion of the 1st web of the hand. The subcutaneous lateral arm free flap is favoured since it allows the procedure to be performed under axilary block.

Arterial Reconstruction for Ulnar Artery Thrombosis Institution where the work was prepared: Wake Forest University School of Medicine, Winston-Salem, NC, USA G.D. Chloros, MD; Robert M. Lucas; Martha Holden; L. Andrew Koman; Wake Forest University School of Medicine

Introduction: The purpose is to evaluate the results of surgical reconstruction of ulnar artery occlusive disease. Materials and

Methods: This is a retrospective study of 15 patients (all male, mean age 43.6 years, range 28 – 59) with symptomatic post-traumatic occlusive disease of the ulnar artery (pure hypothenar hammer syndrome) who were treated with reversed interpositional vein grafting from the ulnar artery to the superficial palmar arch. Patients with concomitant systemic diseases were excluded. All patients were evaluated pre-operatively and at final follow-up using the following health-related qual- ity of life outcome instruments (HRQL): 1) McCabe cold sensitivity severity scale, 2) McGill pain scale, 3) Levine symptom and function scale and 4) WFU symp- tom scale that evaluates pain, numbness and cold intolerance. In addition, digital microvascular perfusion testing (Laser Dopplex Fluxmetry-LDF and Isolated Cold Stress Testing-ICST) was performed pre-operatively and at final follow-up in 24 of the 36 patients. Finally, all patients were evaluated for graft patency as determined by Allen's testing and Doppler ultrasound.

Results: All patients were evaluated for graft patency at a mean of 50.2 months (range 12 – 159) after surgery and all but one vascular grafts were patent. Microvascular perfusion was evaluated at a mean of 52.2 months (range, 12 - 142) and there was statistically significant improvement in all HRQL instrument scores and microvascular perfusion results, except for the LDF which showed no statistically significant change. Conclusion: Successful arterial reconstruction in sympto- matic ulnar artery thrombosis decreases symptoms, improves function and has a positive effect on the health-related quality of life.

A Multicenter Study on the Use of Free Flaps to Preserve Upper Extremity Amputation Levels Institution where the work was prepared: Duke University Medical Center, Durham, NC, USA Alessio Baccarani, MD1; Keith E. Follmar1; Giorgio De Santis, Professor2; Roberto Adani2; Massimo Pinelli2; Marco Innocenti, MD3; Steffen P. Baumeister4; Henning von Gregory4; Günter Germann4; Detlev Erdmann1; L. Scott Levin1; (1)Duke University, (2)University of Modena and Reggio Emilia, (3)A.U.O. Careggi, (4)BG Trauma Center Ludwigshafen/University of Heidelberg

Background: Free vascularized tissue transfer to preserve upper extremity amputation level is an uncommon procedure, and its overall indications may be controversial. This study inves- tigates the role of free tissue transfer in preserving both morphology and function of the amputated upper extremity, from the perspective of a prosthetic rehabilitation.

Methods: Thirteen patients that underwent microsurgical free tissue transfer to preserve upper extremity amputation level were reviewed retrospectively. These cases were selected from four centers: Duke University Medical Center (Durham, NC, USA) University Hospital of Modena (Modena, Italy), Carreggi University Hospital (Florence, Italy), University of Heidelberg (Heidelberg, Germany). Parameters that were evaluated included: age, gender, etiology of the defect, reconstructive procedure, structures to be salvaged, functional outcome and others.

Results: Etiology of the amputation was trauma in 92% of patients. Mean age was 32 years. Only 30% of the cases were reconstructed with an emergency free fillet flap, and in the remaining 70%, a traditional free flap was performed. Structures/functions to be preserved included: pinch function to the hand, elbow joint, shoulder joint, and skeletal length greater than 7 cm. Complications occurred in 38% of the cases, but the final goal of the procedure was achieved in all cases. A treatment algorithm has been devised.

Conclusions: Free vascularized tissue transfer to preserve function to an amputated upper extremity represents a valid option in well selected cases.

150 Free Flap Reconstruction Extends the Indications for Forequarter Amputation Institution where the work was prepared: Helsinki University Hospital, Helsinki, Finland Erkki Tukiainen; Helsinki University Hospital; Outi Kaarela, MD, PhD; Oulu University

Conventionally forequarter amputation (FQA) has been performed for aggressive tumors at the shoulder girdle and the proximal humerus. Distant disease and chest wall involvement have been considered as contraindications to this ablative procedure. Moreover, the wound closure has been was gained with the local posterior tissues. When the invading tumour is located on scapula or the local option for coverage already have been used, also microvascular cover should be considered. In addition, the chest wall resection can also be performed. This extends the conventional FQA.

FQAs performed in two university hospital were retrospectively reviewed (1990 - 2004). The indication was large, primary or recurrent soft tissue sarcomas . In most cases the operation was performed in palliative intention due to unbearable pain, paralysis, oedema, persistent infection and/or ulceration. There were 19 patients, 10 males and 9 females, aged 18 - 78 years. Conventional FQA was performed to eight patients, and in eleven cases the defect was closed with free flap. Two of these patients had and extended FQA including all layers of the chest wall (2-3 ribs). If a free flap was indicated, the remnant forearm was the first choice (7 cases). The bone of the fore arm can be included in the flap to add the skeletal stability of the chest wall reconstruction. If the forearm was not usable due to tumor contamination or severe chronic infection, a tensor fasciae latae free flap was used ( 4 cases). The TFL-flap can be harvested in the lateral position, and the harvest does not affect the respiratory function, which is important especially if also chest wall is resected.

All patients recovered the operation, and the wounds healed primarily. There were no flap losses. Two local recurrences were detected. The survival varied from ? to 5 years, usually the patient died of disseminated disease with pulmonary metastases.

FQA is a mutilating procedure, but in some cases it is the only option to relieve the serious local complications caused by shoulder girdle tumors. Usually the procedure is performed with palliative indications.

Radical Reduction of Upper Extremity Lymphedema with Preservation of Perforators (RRPP) Institution where the work was prepared: E-Da Hospital / I-Shou University, Kaohsiung, Taiwan Paolo Sassu; E-da Hospital / I-Shou University Hospital

Background: Excisional procedures have been successfully utilized by different authors in multi-stage treatment of upper extremity lymphedema. In the last five years we have combined microsurgical principles of perforator flap surgery in order to develop a one-stage procedure that enables a radical reduction of the lymphede- matous tissue with preservation of the vascular supply to the overlying skin.

Methods: Between March 2000 and November 2005 seven patients were treated by Radical Reduction of the subcutaneous tissue with Preservation of Perforators (RRPP). Perforator vessels from the radial and posterior interosseous arteries were identified with a doppler probe and marked. Through medial and lateral forearm inci- sions, skin flaps as thin as 5 mm were raised off the underlying lymphedematous tissue and the affected tissue was removed off the deep fascia. During the dissection, 3 cm of soft tissue was preserved around the perforators in order to avoid their injury and guarantee adequate perfusion of the skin flaps. Medial and lateral antebrachial cutaneous nerves were preserved during the dissection.

Results: At a mean follow-up of 9.1 months all patients showed a significant reduction of the entire extremity and satisfaction from our evaluation. Measurements were evaluated from above and below the elbow joint, at the wrist and the hand. At each of these regions the average percentage reduction was 11.7%, 21.5%, 3.4%, and 5.4% respectively. There were no cases of wound breakdown, skin necrosis or cellulitis in the postoperative period.

Conclusions: Even though further evaluations will be necessary, the application of the angiosome concept to the radical excision of the subcutaneous tissue seems to offer a new promising one-stage surgical procedure in patients affected by upper extremity lymphedema.

Restoration of Dynamic External Rotation by Muscle Transfers in OBPP Institution where the work was prepared: Mircosurgical Research Center, EVMS, Norfolk, VA, USA Julia K. Terzis, MD, PhD; Epaminondas Kostopoulos, M.D.; Eastern Virginia Medical School

Objectives: Restoration of shoulder external rotation is very important to upper extremity function following obstetrical brachial plexus paralysis. The purpose of this study is to present our experience with the secondary restoration of external rotation by the rerouting of latissimus dorsi and teres major muscles in patients with obstetrical brachial plexus palsy.

Methods: From 1978 to 2002, 46 children underwent secondary surgery for the restoration of external rotation (ER). Outcomes were analyzed in relation to various fac- tors including the type of procedure (muscle transfer only, MT, versus nerve exploration and muscle transfer, N+MT), denervation time, type of injury (Erb's versus Global), and severity score. Additionally, the effect of ER restoration on shoulder abduction will be studied.

Results: There was a significant improvement in every case (p<0.01) between preop and postop. The overall mean postoperative achieved Mallet score for the group of muscle transfer (MT) was 3.95 (SD±0.218), while in the other (N+MT) was 3.88 (SD±0.338), (p>0.05). The resulting gain in degrees of external rotation was 990 versus 93.80. Patients with Erb's palsy had a better, but not significant result (p>0.05; p=.94) compared to those with global palsy in both Mallet score (3.77 vs. 3.76) and final active external rotation (81.70 vs. 77.60). In both populations a very significant improvement (p<0.0001) was identified in the final outcome of shoulder abduction (1090 after muscle transfer versus 48.30 before the transfer for the MT group, and 1120 postop after muscle transfer versus 51.60 after neurotization versus 43.80 before any surgery for the N+MT group).

Conclusions: Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

151 ASRM Concurrent Scientific Paper Presentations B-1

Long-term Subjective and Objective Outcome after Primary Repair of Traumatic Facial Nerve Injuries Institution where the work was prepared: Erasmus Medical Center Rotterdam, Rotterdam, Netherlands Marc A.M. Mureau; Erik Frijters; Stefan O.P. Hofer; Erasmus University Medical Center Rotterdam

Background: Traumatic facial nerve injury can lead to varying degrees of facial paralysis. Although it has been generally accepted that primary nerve repair leads to optimal results, there are no follow-up studies evaluating subjective and objective outcome after primary repair of traumatic facial nerve injuries. The aims of the pres- ent study were to assess long-term: subjective facial functioning and satisfaction; objective facial functioning; and physical and mental health.

Methods: From May 1988 to August 2005, 28 patients were operated for traumatic facial nerve lesions. All patients were invited to our outpatient clinic for a standard- ized questionnaire (Facial Disability Index, SF-36), physical examination (Sunnybrook Facial Grading System), and clinical photographs.

Results: There were 21 male and 7 female patients (mean age, 28 years; 9 to 63 years). There were 22 sharp and six crush facial nerve injuries. Left and right side were equally affected. The main facial nerve trunk was severed four times, the temporal branch 10 times, zygomatic branches 12 times, buccal branches 13 times, and the marginal mandibular branch nine times. In four patients all branches were involved, in one case four, in five subjects three, in seven patients two, and in 11 cases one. Concomitant injuries consisted of Stenson's duct transection (7), facial fractures (4), parotid gland injury (9), major neck vessel injury (3), and facial muscle injury (10). End-to-end facial nerve repair was performed within 24 hours in 23 cases (82%) and within one week in the remaining five cases. Concomitant injuries were always repaired as well. Eighteen patients were eligible for follow-up (mean, 6.5 years). Mean Sunnybrook FGS score was 70.4 indi- cating reasonably good facial functioning (100 means perfect), which was better compared to recovered Bell's palsy patients after mime therapy (54.9; p<.05). Mean FDI Physical and Social scores were 84.1 and 80.4, respectively, indicating good subjective facial functioning (100 means perfect). A total of 63.7% and 54.6% were (very) satisfied with facial functioning and appearance, respectively. High positive correlations between Sunnybrook FGS scores and FDI Physical scores and high negative correlations between Sunnybrook FGS scores, FDI Physical scores, and the number of affected facial nerve branches were found. Mean physical and mental health scores (SF-36) were comparable with normative data.

Conclusions: Primary repair of facial nerve injuries leads to good long-term objective and subjective facial functioning with minimal physical and mental health conse- quences. The less facial nerve branches are involved, the better the results.

152 Facial Reanimation with the Masseter-to-Facial Nerve Transfer: Initial Experience Institution where the work was prepared: The Methodist Hospital - Institute for Reconstructive Surgery, Houston, TX, USA Michael Klebuc, MD; The Methodist Hospital

Abstract – ASRM 2007 Annual Meeting – January 13-16, 2007

Background: Adjacent cranial nerve transfers are an important reconstructive option in reanimation of the paralyzed face. This presentation outlines the initial 3 year expe- rience transferring the masseter nerve to selected buccal branches of the facial nerve (CN V- VII transfer) for reanimation of the midface and perioral region.

Patients & Methods: A retrospective review was performed to evaluate 6 consecutive cases of facial paralysis treated with direct microsurgical anastomosis of the masseter to the facial nerve over a 3 year period. Patients were evaluated with physical exam, direct measurement of commissure excursion and video analysis. The group was composed of 3 males and 3 females with ages ranging from 7 to 84 years and an average age of 41.5 years. The causes of facial paralysis were skull base frac- ture (1), Bells palsy (1), acoustic neuroma excision and neurofibromatosis type II (1), petrous apex cholesterol granuloma (1), chronic mastoiditis-skull base osteomyelitis (1) and ruptured intracranial AVM (1). Four patients demonstrated complete hemifacial paralysis and two retained some function in the upper division of the facial nerve. The average time period between the onset of facial paralysis and nerve transfer was 14.3 months. The earliest reconstruction was performed 5 months after the onset of paralysis. The longest time interval before reconstruction was 23 months.

Results: Follow up ranged from 4 to 30 months with an average of 14.2 months with all patients regaining oral competence, good resting tone and a nearly symmet- ric smile. Facial tone returned an average of 4 months after surgery and motion comparable to the unaffected side was present 6.6 months. The vector of the reconstructed smile and degree of motion resembled the normal side. Commissure excursion of the reconstructed side ranged from 1cm to 1.7 cm with an average movement of 1.3 cm. A smile produced without biting down developed in 2 of the 6 patients by the 19th postoperative month. No visible wasting of the masseter muscle or TMJ dysfunction was encountered. Complications included one sialocele and a case of otitis externa.

Conclusion: The masseter-to-facial nerve transfer is an effective method for reanimation of the mid-face and perioral region in a select group of facial paralysis patients. The technique is advocated for its limited donor site morbidity, avoidance of interposition nerve grafts and potential for cerebral adaptation producing a strong, effortless smile.

Resurfacing of Color-Mismatched Free Flaps on the Face With Split Thickness Skin Grafts From the Scalp Institution where the work was prepared: University Health Network, Toronto, ON, Canada Declan A. Lannon, MB, BCh, BAO, FR1; Christine B. Novak, PT, MS, PhD(c)1; Peter C. Neligan, MB, FRCSC, FACS2; (1)University Health Network, (2)University of Toronto

Introduction: Free tissue transfer is commonly used in microvascular head and neck reconstruction. In a significant number of patients, the reconstruction involves the place- ment of a color mismatched skin paddle on the face and this has long been a concern in the reconstructive literature(1). The skin in the scalp region is an excellent color match to the facial skin and may be used as a split thickness graft for resurfacing. The purpose of this study is to report our experience in the resurfacing of these skin paddles using split thickness skin graft harvested from the scalp.

Material & Methods: Following Research Ethics Board approval, a retrospective chart review was performed on patients who had undergone resurfacing of free flaps on the face.

Results: Two males and two females ranging in age from 49 to 72 years had resurfacing of free flaps on the face using split thickness skin grafts harvested from the shaved parietal scalp. All donor sites healed within eight days and had normal hair growth. Only one resurfacing site had a small area of delayed healing. All patients had improved color match in the facial skin paddle.

Conclusion: This preliminary report suggests that resurfacing of color-mismatched free flap skin paddles on the face is a relatively minor procedure that can improve esthet- ic outcome and may merit consideration in appropriate patients.

1. Menick FJ. Facial reconstruction with local and distant tissue: the interface of aesthetic and reconstructive surgery. Plast Reconstr Surg. 1998 Oct;102(5):1424-33.

153 Marriage of Hard and Soft Tissues of the Face Revisited: When Distraction Meets Microsurgery Institution where the work was prepared: New YorkUniversity School of Medicine, New York, NY, USA Jason Spector, MD1; Pierre Saadeh2; Stephen M Warren2; Sunil P Singh2; Pierre Boutros Saadeh2; Joseph G McCarthy2; John W Siebert2; (1)Weill Cornell Medical College, (2)NYU Medical Center

Background: Mandibular distraction osteogenesis (DO) is a powerful clinical tool which is routinely utilized for augmentation of the craniofacial skeleton. Patients manifest- ing severe mandibular hypoplasia may also present with severe soft tissue deficiency. In these cases, mandibular DO alone will not be sufficient to restore appro- priate facial contour and must be complemented by procedures that enhance the overlying soft tissue. Microvascular free tissue transfer is a reliable method to move large quantities of autogenous tissue and has been used in hundreds of cases of facial reconstruction at our institution.

Methods: A retrospective analysis was performed on all patients who had undergone mandibular DO at The New York University Medical Center between 1989-2005. Within that cohort of patients a subgroup was identified who had undergone microvascular free tissue transfer following their DO as part of their craniofacial reconstruction.

Results: Of the 133 patients treated with mandibular DO, eight patients received 12 microvascular free tissue flaps (MVFF). In all cases, free tissue transfer was per- formed subsequent to the completion of D0. The primary diagnoses of these patients were: bilateral craniofacial microsomia (3), unilateral craniofacial micro- somia (2), Goldenhaar syndrome (1), Nager syndrome (1) and Treacher Collins (1). The free flaps utilized were the parascapular fasciocutaneous (10), paras- capular osteofasciocutaneous (1) and fibular osteoctaneous (1). Four patients received staged bilateral free flaps; one patient required two consecutive free flaps to the same location. There were no major complications related to the free flap surgeries. In all cases, facial contour was significantly improved by the combined treatment of mandibular DO and free tissue transfer. In one case, vascularized bone was used to salvage non-union after mandibular D0.

Conclusions: Facial rehabilitation that combines craniofacial and microsurgical techniques allows reconstructive surgeons to obtain satisfactory aesthetic results even in the most challenging reconstructive cases.

Safety and Reliability of the Ulnar Artery Perforator Flap Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Suhail K. Mithani, MD1; Rachel Bluebond-Langner, MD1; Gedge D. Rosson, MD1; Eduardo D. Rodriguez, DDS, MD2; (1)Johns Hopkins School of Medicine, (2)R Adams Cowley Shock Trauma Center and the Johns Hopkins School of Medicine

Background: The radial forearm flap is one of the most common fasciocutaneous free flaps used in head and neck reconstruction. The ulnar artery free flap represents an alternative strategy and may be preferable in some cases since the ulnar forearm is less hirsute, thinner and easier to conceal. Many surgeons are reluctant to use the ulnar artery free flap due to concern for vascular, motor, or sensory compromise to the hand. We evaluated the motor, sensory and vascular outcomes of patients who underwent ulnar artery free flaps.

Methods: We conducted an IRB approved study of 11 patients who underwent ulnar artery free flaps for head and neck reconstruction from 2004-2006. All flaps were performed by a single surgeon (EDR); the dissection was suprafascial and perforator based. Patients returned to clinic for motor, sensory, and vascular testing. Grip strength was tested with the dynamometer. 2 point discrimination distal to the donor site in both median and ulnar sensory distributions was tested with Dellon-MacKinnon Discriminator and compared with the contralateral side. Arterial velocity in both the brachial and radial arteries was assessed by Doppler ultrasound and digital pressures were measured in both hands by Photoplethysmography. Disability was assessed by the quickDASH (Disability of the Arm Shoulder and Hand) questionnaire, which uses simple questions to measure physical function and symptoms in persons with musculoskeletal disorders of the upper limb.

Results: Flap survival was 100% with no donor or recipient site morbidity. The donor site was closed primarily in 2 patients and with a full thickness skin graft from the groin in 9 patients. 10/11 flaps were harvested from the non-dominant hand. The average flap size was 8.2x 5.6cm. The grip strength in the donor hand was within 10% of the contralateral hand in all patients. There was no significant difference in 2 point discrimination in the ulnar nerve sensory distribution compared with median nerve distribution. Digital pressures demonstrated equivalent distal perfusion in the donor hand. After appropriate recovery period, no disability was reported by patients as measured by quickDASH survey. Median follow up time was 15 months.

Conclusions: The ulnar artery perforator free flap, when performed by an experienced microsurgeon represents a viable alternative to radial artery free flaps for head and neck reconstruction. Donor site morbidity is minimal, with potential for improved cosmetic results. There is no evidence of vascular, sensory, or motor compro- mise to the hand.

154 Combining Split Inferior Turbinate (SIT) Mucosal Flaps with Free Flap for Repairing Nasal Cavity in Composite Palatal and Maxillary Defect Reconstructions Institution where the work was prepared: Chang Gung memorial hospital, Taipei, Taiwan C.K. Tsao; Ming-Huei Cheng; Chwei-Chin Chuang; Fu-Chan Wei; Chang Gung Memorial Hospital

Purpose: Free flap reconstruction of extensive composite palatal and maxillary defects involving nasal floor can be difficult (fig. I). Complications such as wound dehis- cence, flap infection or partial necrosis may happen if nasal side mucosa defect is not properly reconstructed. Here we report our experience of combining splint inferior turbinate (SIT) mucosal flaps with free flap for reconstruction of composite palatal defect.

Materials and Methods: From 2003 to 2006, 9 patients had received free tissue transfers in combination with SIT mucosal flaps for composite palate defects at our medical center. The nasal cavity defects involved unilateral or bilateral in 4 and 5 patients respectively. The average defect was 4.9*1.8cm. The SIT flaps were superiorly based (fig. II) providing quite adequate amounts of well-vascularized mucosa for nasal floor reconstruction. The medial SIT flap was sutured to septal mucosa and the lateral one was sutured to residual nasal floor mucosa or to the lateral pharyngeal wall (fig III). The integrity of nasal cavity was thus reestablished.

Results: All of the nasal cavity defects were closed completely with this method. 10 free flaps used in combination with SIT flaps had a total survival without flap infec- tion or wound dehiscence. Fiberscope examination and flow-metry at postoperation 3 months confirmed the maintenance of an adequate nasal meatus with- out nasal obstruction.

Conclusion: We have found the SIT flaps reliable and effective for repairing nasal cavity in patients undergoing free tissue reconstruction for composite palatal and nasal floor defects. It prevents flap infection and palatal wound dehiscence. The inferior turbinate mucosa should be preserved during tumor ablation if it doesn¡?t conflict cancer excision principle so that it can be used for this particular purpose

Fig I Fig II Fig III

The Alliance of Craniofacial and Microsurgery in Composite Mid-Face Reconstruction: Introduction of the Girder System Using the Free Fibula Osteoseptocutaneous Flap Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Julie E. Park, MD1; Rachel Bluebond-Langner, MD1; Paul N. Manson, MD1; Eduardo D. Rodriguez, DDS, MD2; (1)Johns Hopkins School of Medicine, (2)R Adams Cowley Shock Trauma Center and the Johns Hopkins School of Medicine

Background: Maxillary and periorbital defects from either high-energy trauma or oncologic extirpation routinely involve composite tissue loss. Accurate reconstruction of these complex defects requires not only soft tissue coverage but also restoration of the bony architecture. Early work in traumatic craniofacial reconstruction demonstrated the importance of restoring the skeletal buttresses with either non-vascularized bone grafts or titanium plates. In the field of architecture, a gird- er is defined as a main horizontal structure that supports a vertical load. Rather than focusing on exact recreation of the missing curvilinear facial skeleton, the essential girders of the face can be reconstructed using the free fibula osteoseptocutaneous flap with multiple osteotomies. We propose “the girder sys- tem” as a refinement of the facial buttress system for vascularized skeletal reconstruction of the midface.

Materials and Methods: A total of eleven patients underwent reconstruction of the orbitozygomatic complex (n=2), orbit (n=1), orbital rim and maxilla (n=3) or maxilla (n=5) with a free fibula osteoseptocutaneous flap between 2003 and 2005. The majority of patients were male (73%) with an average age of 37 years. Most defects were the result of trauma (n=9).

Results: Nine patients were secondary reconstructions following subtotal resorption of non-vascularized bone grafts, and 2 patients were primary reconstructions of bony defects greater than 5 cm. Ten out of 11 flaps survived. The average length of fibula used was 8 cm (range 6-15cm). One to 2 osteotomies were made in all patients. To date, 3 of the patients who underwent maxillary reconstruction have osseointegrated implants. The average follow-up was 18 months.

Conclusions: The importance of facial buttresses in reconstruction of traumatic craniofacial injuries was realized twenty-five years ago. These valuable principles are equal- ly applicable when reconstructing defects resulting from tumor extirpation or high energy trauma. The introduction of the girder system represents a paradigm shift and evolving partnership between craniofacial and microsurgical reconstruction.

155 Immediate Free Flap Reconstruction in the Management of Advanced Mandibular Osteoradionecrosis Institution where the work was prepared: National Taiwan University Hospital, Taipei, Taiwan Nai-Chen Cheng, MD; Ming-Ting Chen; Hao-Chi Tai; Yueh-Bih Tang; National Taiwan University Hospital

Management of advanced mandibular osteoradionecrosis (ORN) is a difficult and challenging clinical problem. When the patient fails to respond to the con- servative treatments, or has pathological fracture, radical resection of the involved mandible and surrounding soft tissue is necessary. We retrospectively reviewed 13 patients who received immediate free flap reconstruction after radical resection for mandibular ORN from January 1995 to March 2005. All patients were male who received radiotherapy for head and neck cancer. The mean age at the time of surgery was 53.8 years. Among the reviewed cases, eight fibula flaps and five iliac crest flaps were employed. All flaps survived except one fibula flap, which was salvaged with a pectoralis major myocutaneous flap. The mean follow-up time was 5 years and 9 months. Every patient experienced complete resolution of ORN symptoms. No evidence of ORN recurrence was observed, except one developed new ORN at the contralateral mandible five years after the operation. Satisfactory functional and aesthetic outcomes could be achieved in all patients. Our experience showed that radical resection and immediate reconstruction with free composite bone flap offers an effective treatment in select- ed patients with extensive mandibular ORN.

156 ASRM Concurrent Scientific Paper Presentatons B-2

Long term results in the use muscle flaps for salvage of the infected total knee arthroplasties Institution where the work was prepared: cleveland clinic, clinic, OH, USA amardip Bhuller, md1; Wong Moon, MD2; Risal Djohan, MD2; Warren Hammert2; Earl Browne, MD3; (1)clevland clinic foundation, (2)Cleveland Clinic Foundation, (3)The Cleveland Clinic Foundation

Introduction: Deep infections occur in 1-5% of all total knee arthroplasties (TKA) and may result in failure of the prosthesis with subsequent amputation. Two stage re- implantation with a muscle flap is often successful in the salvage of infected total knee arthroplasties. We report a 12 year follow up of group patients suc- cessfully treated with this protocol, and a second group of patients treated with washout and flap coverage. Methods: An IRB approved retrospective review of pts from 1990-2005 with infected TKA's was preformed with chart review, questionnaire and telephone call follow up. Results: 43 patients were found with a range of follow up from 6 months to 12 years. There were two groups of patients treated, 23/43 patients were treated with explantation of the prosthesis and insertion of an antibiotic spacer with staged reinsertion of the prosthesis and flap coverage (group 1). A second group of patients had the knee prosthesis washed out and flap coverage was preformed (Group 2) 30% of all cases involved free muscle transfer with or without addi- tional pedicle muscle rotational flap. The most common organism found was Staph Aureus 19/43 (MRSA 10/43) followed by, Pseudomonas 6/43, Co-ag neg staph 5/43, Enterococcus 4/43, VRE 2/43 and Group B Strep 2/43ther organisms cultured were Stenotrophomonas (Xanthomonas) maltophilia Proteus mirabilis, , Acinetobacter calcoaceticus-baumannii. Overall acute Limb salvage was achieved in 97 % patients with a long -term salvage rate of 91%.The acute failure resulted in a failure within one month after the flap, the other failures occurred because of recurrent infection at six months and at 2years. Group 1 achieved 92 % success rate and group 2 a 90% suc- cess rate. There were two failures in patients treated with free muscle transfer with or without a pedicled flap, and two using pedicled muscle flaps alone. Overall patients requiring free muscle transfer were a high risk population where a 77% limb salvage rate was achieved. The patients where pedicled muscled flap was used alone achieved a 94% success rate.

In 32 pats where follow up was obtained 28 patients achieved pain free ambulation. Conclusion The use of muscle flaps achieved a 91% long term limb salvage rate in infected total knee arthroplasties. Patients had a good quality of life, and pain free ambulation was achieved in 28/36 patients. Amputation in infected knee prosthesis can be avoided with the use of muscle flaps adhering to these protocols.

Fasciocutaneous versus Muscle Flaps Following Lower Extremity Trauma: A Pilot Study of Functional Outcomes Institution where the work was prepared: R Adams Cowley Shock Trauma Center, Baltimore, MD, USA Rachel Bluebond-Langner, MD1; Navin K. Singh, MD1; Gedge D. Rosson, MD1; Suhail Mithani1; Eduardo D. Rodriguez, DDS, MD2; (1)Johns Hopkins School of Medicine, (2)R Adams Cowley Shock Trauma Center and the Johns Hopkins School of Medicine

Background: There has been an increase in the use of free fasciocutaneous flaps versus free muscle flaps for reconstruction of traumatic lower extremity wounds. Functional outcomes of lower limb salvage compared to amputation have been previously studied. However, there are little data comparing outcomes among different coverage options. We sought to compare functional outcomes of fasciocutaneous flaps versus muscle flaps with skin grafts. Methods: We conducted an IRB approved retrospective review of 120 patients with lower extremity trauma who underwent free tissue transfer between 1998 and 2005 at the R Adams Cowley Shock Trauma Center. The majority of the patients were male (69%) with an average age of 42 years. 29 of these patients agreed to participate in the study and completed the SF12, SMFA and supplemental questions written by the authors. A physical therapist evaluated five tasks. Sensation of the donor site was measured using the PSSD machine. The donor sites for the muscle free flaps included the rectus abdominis and gracilis muscles. All fas- ciocutaneous flaps were from the anterolateral thigh. Results: The mechanism of injury was largely blunt (n=27). 51.7% patients had coverage with a fasciocutaneous flap and 48.3% with a muscle flap. The most com- mon defect location was the distal third of the leg (n=20), followed by the middle third (n=4), foot (n=3) and proximal third (n=2). 11 patients had contralat- eral orthopedic injuries. The average follow up was 18 months in the fasciocutaneous group and 47 months in the muscle group. Functional outcomes (i.e. physical, emotional, social, societal) measured by the SF 12, SMFA and physical therapist demonstrate equivalence (p >0.05). Satisfaction with cosmetic appear- ance was equivalent (p>0.05) with a trend toward women being less satisfied than men overall (p=0.06). 97% of patients would go through the limb salvage process to avoid amputation. The one patient who would have preferred an amputation had a pain score greater than 2 standard deviations above the mean. Sensation at the donor site, measured with PSSD, was diminished in all patients however the fasciocutaneous flap donor sites had more significant sensory loss (p=0.005). Conclusion: Both fasciocutaneous and muscle flaps provide vascularized tissue which covers hardware and nourishes the fractured bone however muscle flaps pilfer a full muscle unit which may not be inconsequential in a trauma patient. The results of this pilot study suggest no functional differences between patients whose traumatic defects are covered with free fasciocutaneous flaps or muscle flaps.

157 Shift of Concepts in the Management of Open Tibial Fractures Institution where the work was prepared: Department of Hand, Plastic and Reconstructive Surgery, Ludwigshafen, Germany Christoph Heitmann; Christoph Czermak; Emilios Nalbantis; Günter Germann; University of Heidelberg

Background: Since the year 2000 we treat open tibial fractures with the „orthoplastic team approach“ knowing, that there is a postulated “golden window” for the treat- ment such as “Fix and Flap” within 72 hours post trauma. All patients were reviewed retrospectively with the following questions: 1. How realistic is the “gold- en window”? 2. Is it important in terms of salvage versus amputation to keep within the „golden window“? 3. How does the patient satisfaction correlates with a specific type of flap?

Patients and Methods: From January 2000 to July 2005 we treated 92 patients with open tibial fractures. 25 patients were treated exclusively in our clinic, 67 patients have been referred after initial bony fixation. There were 72 men and 20 female with a mean age of 46 (10-79) years. We reviewed the time between trauma and flap reconstruction, type of flap and complications. During follow up we used a questionaire to assess the functional and subjective outcome (Functional ques- tionaire Hannover- FFbH)

Results: The following flaps have been used: Latissimus dorsi (59), Gracilis (16), Rectus abdominis (2), ALT (11), Parascapular (2), Radial forearm (1), lateraler arm flap (1). There were 8 flap losses (8,6 %). 5 of these patients received a second free flap, in three cases a lower leg amputation was performed. The mean time between trauma a flap coverage was 18,6 (4-59) days. 66 patients could be recruited for follow up (71%). There was no significant difference in terms of functional out- come between muscle flaps and fasciocutaneous flaps. However, in the section aesthetic outcome, the fasciocutaneous flaps were superior to muscle flaps.

Conclusion: The results of the management of open tibial fractures demonstrate, that in clinical reality the „golden window“ was never reached. But this had no conse- quence for successful extremity salvage. The functional outcome was determined by the quality of the bony fixation and not by the type of flap used. However, there is a strong trend in our clinic to use fasciocutaneous flaps whenever possible, because the aesthetic outcome is much improved compared to muscle flaps.

Gustilo Grade IIIB Tibial Fractures Requiring Microvascular Free Flaps: External Fixation Versus Intramedullary Rod Fixation Institution where the work was prepared: NYU Medical Center/Bellevue Hospital, New York, NY, USA Christine Rohde, MD1; Matthew R. Greives1; Curtis L. Cetrulo Jr, MD2; Oren Z. Lerman, MD1; Alexes Hazen, MD1; Jamie P. Levine, MD1; (1)NYU Medical Center/Bellevue Hospital, (2)Nassau County Medical Center

Gustilo IIIB fractures involve high energy tibial fractures for which there is inadequate soft tissue coverage.

In addition to orthopedic fixation, these injuries often necessitate a microvascular free flap. Although much has been written in the orthopedic literature favor- ably comparing intramedullary (IM) rod or nail fixation to external fixation (ex-fix) in open tibial fractures, these studies have not focused on the role of either method of fixation in relation to the soft tissue reconstruction. As the use of IM rods in complex fractures has increased over the past ten years, we have noted numerous complications after providing free flap soft tissue coverage over these rodded fractures. We sought to investigate whether there were differences in outcomes between free flap-covered lower extremity fractures which were fixated by external fixation versus intramedullary rodding. A retrospective chart review was performed on all patients in our institution who had lower extremity microvascular free flaps for coverage of Gustilo IIIB fractures from 1995-2005 in rela- tion to the type of bony fixation. Of the 38 patients studied, twenty underwent external fixation of the tibial fracture, and eighteen had intramedullary rod- ding. Overall free flap survival was 95% with one failure in each group. However, the IM rod group had a higher incidence of wound infection, osteomyelitis, and bony nonunion (25%, 25%, and 40%, respectively) than the ex-fix group (6%, 11%, 17%, respectively). For Gustilo IIIB fractures that require free flap cov- erage, the added bony and soft tissue manipulation required for intramedullary rodding may disrupt the surrounding blood supply and lead to higher rates of complications. These complications necessitate additional operations and threaten the overall success of the reconstruction. Plastic surgeons and orthopedic surgeons should discuss the optimal method of bony fixation for high energy tibial fractures when a free flap will likely be needed for soft tissue coverage.

Pitfalls in Reconstruction of Heel Defects Due to Ground Landmine Explosions Institution where the work was prepared: Gulhane Military Medical Academy. Depart. of Plastic Surgery, Ankara, Turkey Serdar Ozturk, Assoc, Prof; mustafa sengezer; fatih Zor; murat turegun; Gulhane Military Medical Academy

Landmines are among the high-energy weapons that explode when a man steps on them and steps off. Ground landmine explosion results in severe complex soft tissue and bone defects especially on the heel area. Such injuries bring a formidable challenge to both patients and reconstructive surgeons. Here, we pres- ent one of the largest series of patients with complex heel defects due to landmine explosion. We discuss our experience as well as the pitfalls of reconstruc- tion. MATERIAL-METHODS 72 out of 135 patients who had heel defects treated with muscle flaps in Department of Plastic and Reconstructive Suregry at GMMA were included in the study.Type of injury, localization of the wounds, tissue defects and timing of the definitive treatment were examined retrospec- tively. Treatment modalities according to the severity and localization of the wounds were defined. Our preference for reconstruction of large complex defects was free muscle flaps covered by split-thickness skin grafts. Among these, we used free latissimus dorsi muscle flaps in 42 patients, and rectus abdominis mus- cle flaps in 30 patients. Late functional results of the patients were evaluated by clinical observation, a questionere, three dimensional gait analysis, dynamic podography, and dynamic EMGs. The mean follow-up of these patients was 5.6 years ranging from 1 to 11 years. The values were compared with both the results of the intact foot of the patient and with the ones obtained from 20 healthy volunteer men (control group).Statistical analysis were performed by Mann- Whitney U and Wilcoxon (non-parametric) tests. RESULTS Chronic and repetitive ulcerations (24patients, 33%) and chronic discharge through the ulcer (20 patients, 27.8%) were found. Most of the patients declared their satisfaction of having their own feet instead of prosthesis. 41 patients are still working with- out any difficulty for a mean of 3.4 years (range, 1 to 8 years). And, the mean time of standing or walking per day was 2.85 hours for the rest of the patients. Dynamic pressure distribution tests revealed significantly higher pressure and load values on the injured feet of the patients than the control group(p<0.05). 3-D motion analysis showed restricted range of motion(ROM) at the ankle and hip joints of the injured extremity and the difference was significant statistically(p<0.05). CONCLUSION Reconstructive options should always be preferred to the amputation procedures in extensive tissue losses of the heel due to mine explosion. Free muscle flaps are promising in reconstruction of such extensive heel defects due to high-energy landmine injuries.

158 Achilles Tendon Reconstruction with the Gracilis Musculotendinous Free Tissue Transfer: A Single-Institution Experience Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, USA Bauback Safa, MD1; Charles K. Lee2; Gil S. Kryger, MD1; Gregory M. Buncke3; (1)Stanford University, (2)The Buncke Clinic, (3)California Pacific Medical Center

Background: The surgical management of Achilles tendon defects represents a significant reconstructive challenge. Various techniques have been described including local flap coverage as well as microvascular free tissue transfer for single-stage reconstruction of the Achilles tendon. Each technique has its limitations; however, the functional and anatomical requirements of Achilles tendon reconstruction with both soft tissue and tendon constraints point to an ideal flap option—the gracilis musculotendinous unit. We report our single-institution experience with the gracilis free tissue transfer for Achilles tendon reconstruction.

Methods: A retrospective chart review was performed for 14 patients who underwent Achilles tendon reconstruction with a gracilis free tissue transfer. The gracilis ten- don was used to bridge the Achilles tendon defect with intratendinous weaving and the muscular portion was folded over to cover the tendon repair with a split thickness skin graft. Microvascular anastomosis was performed to the posterior tibial artery and vein. Parameters measured were age, sex, comorbidities, wound type, length of open wound, size of wound (soft tissue and Achilles defect), complications, and follow-up time. Patients were evaluated for range of motion, ambulation, heel height in the tiptoe position, climbing stairs, and donor site morbidity.

Results: All 14 gracilis flaps were successful with no flap loss. The mean patient age was 47. The average wound size was 13 cm2 with an average Achilles tendon defect of 3.4cm. One patient had partial skin graft loss which healed with local wound care. One patient developed a donor site seroma which required surgi- cal drainage. There was one case of intraoperative venous thrombosis requiring a vein graft. There were no cases of early or late tendon ruptures or further infection. Patients had an average plantar flexion of 100 degrees and reported no difficulty with ambulation. All reconstructed Achilles tendons showed good functional and aesthetic results. All patients returned to their previous level of activity and could stand on tiptoes on the affected foot.

Conclusion: The gracilis musculotendinous free tissue transfer represents an ideal reconstructive modality for a single-stage, vascularized reconstruction of the Achilles ten- don and soft tissue. It is ideal for moderate to large defects with a high success rate and longevity with minimal donor site morbidity. Patients who have under- gone this procedure demonstrate excellent functional and aesthetic outcomes and have been able to return to their previous level of activity.

Fibula Free Flap Reconstruction of the Ilium in Children after Resection of the Hemipelvis Institution where the work was prepared: Children's Hospital of Philadelphia & University of Pennsylvania, Philadelphia, PA, USA Darrin M. Hubert, MD1; John P. Dormans, MD2; David W. Low, MD1; Benjamin Chang, MD2; (1)University of Pennsylvania, (2)The Children's Hospital of Philadelphia

Introduction: Neoadjuvant chemotherapy for Ewing's sarcoma has made wide resection with limb salvage frequently possible. However, resection of iliac tumors causes prox- imal pelvic migration and significant leg length discrepancy. Free vascularized bone autografts represent the optimal method for iliac reconstruction because they heal faster and hypertrophy sooner than nonvascularized bone grafts. Furthermore, they may be more durable in the setting of neoadjuvant chemother- apy or radiation therapy.

Purpose: The purpose of this study is to characterize the successful reconstruction of the ilium in children using the fibula free flap following resection of the hemipelvis. Methods: Four patients were identified who underwent fibula free flap reconstruction of the pelvis after resection of the ilium, with preservation of the hip joint. All had Ewing's sarcoma of the iliac wing without evidence of metastasis (stage IIB) and had pre-operative chemotherapy. Review of their operative records and clinic charts was performed.

Results: Mean age was 13.4 years (range 10-14). Mean follow-up was 4.0 years (1.5-5.3). Mean time to union of the fibular struts was 6.8 months (6-9.5). All patients began toe-touch weight-bearing ambulation with crutches following removal of their trunk spica casts at 8-12 weeks. Lengths of the fibula free flaps were 20, 25, 18, and 17 cm. Mean leg length discrepancy was 2.3 cm (1.0-3.5 cm). No flap loss or post-operative infection occurred. All patients remained with- out metastasis or local recurrence. Trendelenberg gait was noted in three patients due to loss of lower extremity abduction following iliac resection. One patient underwent subsequent contralateral lower extremity epiphysiodesis to correct leg length discrepancy.

Conclusion: Successful reconstruction of the pelvic ring utilizing a triangular double-barreled fibula free flap in four children is described along with functional outcomes. Early union followed by early weight-bearing may be critical to minimize the leg length discrepancy in the immature skeleton of the pediatric population.

159 A long-Term Study Of Donor Site With A Split Fibula Bone Graft After Vascularized Fibula Flap Transfer In Head And Neck Surgery Institution where the work was prepared: Chang Gung Memorial Hospital, Kaohsiung, Taiwan Shun-Man Cheung, MD; Seng-Feng Jeng; Yur-Ren Kuo; Ching-Hua Hsien; Chang Gung Memorial Hospital

Background: The fibula osteocutaneous flap is recently used for mandibule reconstruction in head and neck surgery after cancer ablation. However, the long term effects showed persistent pain, decrease range of motion and even ankle instability. The purpose of this study is to restore the original length of fibula bone by using a split fibula graft which was a part of the original graft, to provide the divided muscle to be reattached, and by doing this procedure to improve the ankle stability and muscle power.

Patients and Methods: From January 2002 to December 2003. Fifty patients of head and neck cancer underwent a total 50 fibula osteocutaneous free flap for mandibular recon- struction. All the reconstructions were performed by the same senior author. Group-I:25 patients the conventional group, the distal remnant of fibula is at least 6 cm. Group-II:25 patients, the donor fibula is reconstructed with a splint fibula graft with AO plates and screws. The clinical evaluation and routine X-Rays of ankle joints were taken at least 6 months postoperatively. The functional evaluation was undergo isokinetic testing by Cybex II dynamometer one year post- operatively. For each patients, the range of maximal voluntary ankle motion (inversion, eversion, flexion and extension) in each leg. If there was>20% differ- ence, we would define significant deficit.

Results: After at least 2 years follow up. In group I there was 14 patients and in group II 10 patients could complete the final evaluation. X-ray of Group II shows good aligament of bone graft and bone union of the patients, except one patient developed malunion of bone graft, this patient need autogenous bone graft at second stage. The Cybex-II dynamometer showed the 60 degrees and 120 degrees of ankle eversion or inversion had no significant difference between two group, also in ankle dorsi 60o and 120o ankle plantar 60o. However, the peak tourque ratios of ankle plantar 120o. Showed significant difference in Group II P<0.05 (Reconstructed group) with Chi-Square tests. All the patient could ambulate normally without any problems subjectively.

Conclusion: The free fibula osteocutaneous flap for mandibular reconstructive after head and neck surgery is a safe procedure. The donor site morbidity is minimal. However, to use a split fibula graft to reset its original length would provide the divided muscles to be reattached, and its muscle power (ankle plantar 120o) would increase compared with conventional method Group I.

160 ASRM Concurrent Scientific Paper Presentatons C-1

A New Composite Tissue Allograft Transplantation Model for Reconstruction of the Head and Neck Defects and Long Term Survival Permitted by Donor Specific Chimerism Under Low Dose Cyclosporine A Treatment Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Yalcin Kulahci; Aleksandra Klimczak; Maria Siemionow; The Cleveland Clinic Foundation

Background: Extensive head and neck deformities including bone and soft tissue defects are always challenging for reconstructive surgeons. The purpose of this study was to extend application of the face/scalp transplantation model in rat by incorporation of the vascularized mandible, masseter and tongue, based on the same vascular pedicle, as a new reconstructive option for extensive head and neck deformities with large soft and bone tissue defects.

Methods: A total of 12 composite osseomusculocutaneous hemiface/mandible-tongue transplantations were performed in two experimental groups. Group 1 isotrans- plantation between Lewis rats served as control without treatment (n=6). Group 2 (n=6) composite hemiface/mandible-tongue transplants were performed across MHC barrier between Lewis-Brown Norway (LBN, RT11+n) donors and Lewis (RT11) recipients. Hemifacial flaps including hemimandibular bone, mas- seter muscle and tongue were dissected on the same pedicle of external carotid artery and jugular vein and were transplanted to the donor inguinal region. All allogenic transplant recipients received 16mg/kg/day of CsA monotheraphy tapered to 2 mg/kg/day and maintained at this level thereafter. All animals were monitored for sign of allograft rejection such as erythema, edema, hair loss, desquamation. Flap angiography and CT scan evaluated allograft viability. Flow cytometry assessed donor-specific chimerism for MHC class I- RT1n antigen. H&E staining revealed bone histology, hemotopoietic activity and tested inflam- matory response and grade of allograft rejection.

Results: Isograft controls survived indefinitely. Six hemiface/mandible-tongue allotransplants survived up to 200 days (still under observation). Flap angiography demon- strated intact vascular supply to the bone. No signs of rejection and no flap loss were noted. CT scan and bone histology confirmed viability of bone compo- nents of the composite allografts. Viability of tongue was confirmed by pink color, bleeding after puncture and histology. H+E staining determined the pres- ence of viable bone marrow cells within transplanted mandible. Donor-specific chimerism at day 100 posttransplant was established for by presence of donor T-cells (2.7% CD4/RT1n, 1.2% CD8/RT1n) and B-cells (11.5% CD45RA/RT1n).

Conclusions: We have introduced a new model of composite osseomusculocutaneous hemiface/mandible-tongue allograft transplant. Long-term allograft acceptance was accompanied by presence of donor specific chimerism supported by vascularized bone marrow transplant of the mandibular component. This model may serve as a new reconstructive option for coverage of the extensive head and neck deformities involving large bone and soft tissue defects performed in one-stage surgical procedure.

Potential Approaches to Face Harvest for Face Transplantation Institution where the work was prepared: Duke University Medical Center, Durham, NC, USA Alessio Baccarani, MD; Keith E. Follmar; Jeffrey R. Marcus; Detlev Erdmann; L. Scott Levin; Duke University

Background: Total face transplantation has begun to emerge as a reconstructive option in the treatment of patients with massive facial disfigurement. The challenges asso- ciated with immunosuppression and the ethical issues surrounding face transplantation are substantial. One of the most significant technical questions that remains to be answered before the first total face transplant can be performed is how a facial allograft would be harvested and what tissues it would include. We present two novel face harvesting techniques based on our understanding of the vascular anatomy.

Methods: The first technique harvests the skin and soft tissue of the face by dissecting in a subgaleal, sub-SMAS, subplatysmal plane. The second technique harvests the entire soft tissue and bony structure of the face by dissecting in a subperiosteal plane and harvesting the bones of the midface by performing a Le Fort III osteotomy. These techniques were performed on fresh human cadavers that had been perfused with latex.

Results: Each face was harvested successfully as a bipedicled flap based on the external carotid arteries, the external jugular veins, and the facial veins. The sub-SMAS flap appeared to be well perfused by the external carotid system throughout. The subperiosteal Le Fort III flap appeared to be well perfused everywhere except for portions of the zygomatic arch and the sphenoid bone.

Conclusions: Each of these two techniques is a theoretically viable approach to face harvesting for face transplantation and they address different reconstructive needs. Substantial challenges remain before face transplantation can become a viable reconstructive option.

161 Coronal-Posterior Approach for Facial/Scalp Flap Harvesting in Preparation for Facial Transplantation Institution where the work was prepared: Cleveland Clinic, Cleveland, OH, USA Yalcin Kulahci; Maria Siemionow; Frank Papay; Risal Djohan; Warren Hammert; Mark Hendrickson; James Zins; The Cleveland Clinic Foundation

Background: In this study we have developed a new technique, the coronal-posterior approach, for facial/scalp flap harvesting in cadaver model. Our goal was to gain the extended length of sensory nerves within facial flaps via osteotomy approach.

Methods: In this study, 10 fresh human cadavers were dissected. The whole facial-scalp flap was harvested in 5 cadavers using anterior standard approach and in 5 cadav- ers using posterior-coronal approach. For coronal-posterior approach, a posterior midline vertical incision from scalp hairline to the vertex of the scalp was per- formed to the subgaleal plane. From the vertex, a bilateral w plasty incision was designed in a coronal fashion extending to the both postauricular regions. From the lower end of the vertical incision, horizontal incisions were extended bilaterally to be met anteriorly in the neck midline at the suprasternal notch at the depth of the platysma. The flaps were based on external carotid artey and jugular vein. The length of supraorbital and infraorbital nerves was extended by osteotomy at the level of nerves exit from the foramens and mental nerves by sagittal split osteotomy of the mandibular ramus.

Results: The mean length of the supraorbital, infraorbital and mental nerves in posterior-coronal approach was 3.52 ± 0.31cm, 4.65 ± 0.20cm, 5.6 ± 0.14cm respective- ly. This is an increase of 2.02 ± 0.16cm, 2.19 ± 0.05cm and 2.58 ± 0.23cm, respectively, when comparing to standard anterior approach, without osteotomy.

Conclusion: Based on anatomical dissections, in this cadaver study we have introduced a new technique for facial/scalp flap harvesting. Using this coronal-posterior approach we have gained extended length of sensory nerves within facial flap which will facilitate nerve coaptation and will reduce surgery time of face trans- plantation.

Donor/Recipient Compatibility and Morphological Outcomes of Face Transplantation: a Cadaver Study Institution where the work was prepared: Duke University Medical Center, Durham, NC, USA Alessio Baccarani, MD; Keith E. Follmar; Raja R. Das; Srinivasan Mukundan; Jeffrey R. Marcus; L. Scott Levin; Detlev Erdmann; Duke University

Background: Face transplantation may become an option in the treatment of patients with acquired facial deformity. Questions remain to be answered before face trans- plantation becomes a viable therapeutic option. The anthropometric and aesthetic outcome of a face transplantation is of great relevance to the surgeon in order to answer the technical question of whether a given donor face is compatible with the recipient's needs. Furthermore, the question of how the chimeric face of a transplant recipient would appear when compared to his or her native face and to that of the donor is of great interest and importance.

Methods: Four adult cadaver heads of different sizes and ethnic origin were studied. The face was harvested off of each in a subgaleal, sub-SMAS, subplatysmal plane. The harvested faces were then switched among the four donor crania and inset according to a surgical inset plan. Eight chimeric face/cranium combinations were created. Each chimer and each of the four native heads was analyzed photographically and radiographically using computed tomography.

Results: All transplantations were technically feasible. Anthropometric measurements of chimeric faces were generally similar to those of the transplant recipient, and were less similar to those of the donor. Four morphological parameters to consider in determining donor/recipient compatibility were defined: 1) skin color and texture, 2) head size, 3) soft tissue features, and 4) gender.

Conclusions: This study has evaluated the outcomes of a series of mock face transplantations, with a focus on morphological aspects. A set of basic compatibility parame- ters to evaluate donor/recipient compatibility has been defined. It has been shown that, when an appropriate face is chosen, the bony structure of the under- lying cranium can give the chimer an appearance that is quite similar to that of the recipient's native face. The dual challenges to projecting outcome of face transplantation and defining compatibility parameters are best fulfilled through multiple iterations of cadaver rehearsal surgeries, such as these. Despite the huge challenges, we believe that such a procedure will some day become a valuable therapeutic option in the management of facial disfigurement.

162 Role of Graft-Derived Dendritic Cells in Skin Allograft Acceptance in Hemifacial Allograft Transplant Model Institution where the work was prepared: The Cleveland Clinic Foundation, Cleveland, OH, USA Aleksandra Klimczak, PhD; Galip Agaoglu; Sakir Unal; Maria Siemionow; The Cleveland Clinic Foundation

Introduction: Clinical application of composite tissue allograft transplants opened discussion on the restoration of facial deformities by allotransplantation. We have former- ly achieved operational tolerance in fully MHC mismatched rat hemifacial allotransplantation model under low dose of cyclosporine-A (CsA) monotherapy with- out side effect. The potential of graft-derived dendritic cells (DC) contribution to chimerism induction and allograft survival was tested in hemiface transplants, across MHC barrier, under CsA monotherapy.

Methods: Twenty four hemiface transplantations were performed in 4 groups (6 rats each). Allograft rejection controls included transplantation between semi-allogenic LBN(RT1l+n) (Group 1) and fully-allogenic ACI(RT1a) (Group 2) donors without treatment. In allograft treatment groups, recipients of LBN grafts (Group 3) and ACI grafts (Group 4) were treated with CsA monotherapy at dose of 16 mg/kg/day, tapered to 2 mg/kg/day and maintained at this level thereafter. Evaluations were scheduled at different time-point (7, 28, 63, 100 days) for the lymphoid organs and blood harvesting. Flow cytometry monitored donor-spe- cific chimerism (MHC class-I RT1n and RT1a antigens). Immunofluorescence evaluated migratory potential of donor cells from face graft to lymphoid organs. Mechanism of allograft acceptance was assessed by the presence of donor dendritic cells (DDC) and apoptotic cells (TUNEL technique) within lymphoid organs of recipients.

Results: All face transplants under CsA monotherapy from LBN and ACI donors displayed presence of passenger leukocytes within lymphoid organs of recipients. At day 7 post-transplant DDC and donor leukocytes were detected within spleen and lymph nodes of face recipients. During follow-up, the number of donor-origin DC significantly increased within spleen but only single cells were present within lymph nodes. DDC were not detected within thymus. Donor-specific chimerism was present in the peripheral blood of recipients at day 100 post-transplant: for LBN recipients 1.4% CD4/RT1n, 0.5% CD8/RT1n and 2.6% CD45RA/RT1n; for ACI recipients 16.8% CD4/RT1a, 3.7% CD8/RT1a Apoptotic cells were detected in the lymphoid organs of recipients as early as day 7 and during entire follow-up period (100 days) and reflected anergy of T-cells.

Conclusions: CsA monotherapy promoted T-cell tolerogenicity of DDC in hemifacial allograft transplants due to stabilized functionally immature status of dendritic cells. Migration and localization of graft-derived DDC into lymphoid organs of recipients confirmed immunomodulatory function of DDC in skin allograft accept- ance in hemifacial allograft model. Anergy of T cells, demonstrated by the presence of apoptotic cells within lymphoid organs of face recipients, contributed to long-term hemifacial skin allograft survival.

Functional Study of Motor and Sensory Recover of Facial Allotransplantation. Experimental Study in Rats Institution where the work was prepared: Clinica Aston, Valencia, Spain Pedro C. Cavadas, MD, PhD; Luis Landin; Clinica Aston

Background: Facial transplantation has raised enormous interest recently. Although there are animal models and two recent clinical cases, the functional recovery of a face allotransplantation has not been demonstrated so far. The authors studied the motor and sensory recovery of a hemifacial allotransplantation in the rat model.

Material and Methods: 20 Wistar-Lewis RT1 rats were divided into 2 groups. In group A (10 rats) a hemifacial transplantation from Long-Evans rats was performed without nerve repairs. In group B (10 rats) the hemifacial transplantation was performed from Long-Evans rats, with surgical repair of the infraorbitary branch of the trigem- inal nerve and the bucolabial, upper marginal mandibular and zygomaticoorbitary branches of the facial nerve. Monotherapy with tracrolimus (8 mg/Kg/day, tapering down to 2 mg/Kg/day at 4 weeks and thereafter) was administered to both groups. Due to the 50% perioperative mortality, approximately twice as many rats were operated on in both groups to obtain 10 survivors. At 6 weeks electroneurography and electromyography were obtained. Sensory recover was assessed by the withdrawal reaction to whisker pull.

Results: There was 50% perioperative mortality. Nerve conduction studies in the facial nerve showed no conduction in group A, and a somewhat delayed nerve action potential in group B. Electromyography showed complete denervation of the mystacial muscles in group A, and a rich motor activity in group B. Withdrawal reaction was absent in animals from the group A, whereas in group B the reaction was brisk.

Conclusions: Motor and sensory recover has been demonstrated in hemifacial allotransplantation through major histocompatibility barrier under monotherapy immunesu- pression.

163 Hindlimb Osteomyocutaneous Flap can Create Mixed Chimerism and Donor-Specific Tolerance to Composite Tissue Allotransplantation with the Nonmyeloablative Conditioning in Rats Institution where the work was prepared: Department of Plastic and Reconstructive Surgery, Chang Gung Mem, Taipei, Taiwan Wei-Chao Huang, MD; Jeng-Yee Lin; Chung-Rong Ho; Yu-Hsuan Hsieh; Nai-Jen Chang; Fu-Chan Wei; Chang Gung Memorial Hospital

Introduction: Composite tissue allotransplantation (CTA) such as knee and hand transplants may be regarded as vascularized bone marrow transplantation (VBMT). It has been proven that lymphohematopoietic reconstitution with VBMT was faster than bone marrow (BM) cell infusion. BM cells from the donor vascularized bone graft (VBG) may induce chimerism. The majority of these chimeras undergo tolerance while a minority develops graft versus host disease (GVHD) in rats. We report here the use of hindlimb osteomyocutaneous flap transplantation can induce donor-specific tolerance to CTA with the nonmyeloablative conditioning.

Methods: Male (10- and 12- week old) Brown Norway rats (RTA1C) were donors and male (10 – to 12-week old) Lewis rats (RTA1l) were recipients. Experimental groups were: Group I: syngeneic control without total body irradiation (TBI). Group II: allogeneic control without TBI. Group III: TBI with 600 cGy. Group IV: TBI with 400 cGy. Group V: TBI with 200 cGy. Group VI: without TBI. Recipients in group III, IV, V, and VI were treated with 5 mg anti-lymphocyte serum (ALS) intraperi- toneally (IP) and TBI on day-1, tacrolimus (1mg/kg) IP from days 0 to 10, and 5mg ALS IP on day 10. All of recipients were transplanted with hindlimb osteomy- ocutaneous flap on day 0. Before transplantation, the BM cells in the bone cavity were flushed and curettaged. Chimerism level and multilineage cells were assessed by flow cytometry after transplantation. In vitro T-cell responses were evaluated by mixed lymphocyte reactivity (MLR) assays.

Results: Group I accepted the syngeneic grafts permanently. Allografts in Group II were rejected within 14 days. GVHD was observed in 20% group III. The acceptance rates of allograft were 80% in group III, 60% in group IV, 20% in group V and 0% in group VI. (Fig 1) Chimerism levels after flap allotransplantation were proportional to dose of TBI. The chimerism was durable in group III, but lost in group IV, V and VI with time. The donor multilineage cells could be detected in the recipient blood with allograft acceptance. MLR confirmed tolerance in tolerant recipients.

Conclusion: Hematopoietic stem cells (HSC) in the VBG can create chimerism and tolerance to CTA in the nonmyeloablative conditioning. VBG in CTA directly offers the BM niches of HSCs. Although maro-chimerism could be lost with time, tolerance to allograft still existed in this experiment. We conclude that timing of macro- chimerism is critical for tolerance induction in the early phase of CTA with the nonmyeloablative conditioning.

Nerve Regeneration Through Nerve Autografts and Cold Preserved Allografts Using Tacrolimus (FK506) in a Facial Paralysis Model: a Topographical and Neurophysiological Study in Monkeys Institution where the work was prepared: Clínica Universitaria, Universidad de Navarra, Pamplona, Spain Cristina Aubá, MD, PhD; Bernardo Hontanilla, MD, PhD; Juan Arcocha; Oscar Gorría; Clínica Universitaria, Universidad de Navarra

The regeneration through nerve allografts temporarily treated for two months with FK506 does not reach the results obtained with autografts, at least in terms of brain stem neuron number and electrophysiological recordings. There was an almost 70% lower neuronal population in the allograft group and it mainly corresponded to missing small motoneurons. This lower participation of neurons is somehow compensated by collateral axon sprouting, which maintains the electrical activity of the target muscle and allows it to produce normal facial movement. The plasticity of the peripheral nervous system is so prepared to com- pensate for deficits in any level of its circuit that, in order to detect impairment of clinical results, the structural damage to the neural system must reach at least 70%, as also occurs in other organs like the liver, kidney or pancreas. Thus, autografts or allografts may present similar clinical results although there is an important neuronal impairment in the brain stem that is related to the small neurons that maintain electrical activity to the slow twitch muscle fibers. Finally, the cessation of immunosuppression after two months in 4 cm long nerves leads to a partial graft rejection, but this does not diminish the functional move- ment of the mimic muscles of the monkeyxs face. More experimental research is necessary to demonstrate if nerve regeneration occurs through long nerve allografts.

164 The Possibility to Use Laterally-sprouting Axons at The Nerve Repaired Site as Motor Sources to innervate a Functioning Free Muscle Transplantation ( FFMT) - Study in Rats Institution where the work was prepared: Chang gung memorial hospital, Taipei, Taiwan C.K. Tsao; David CC Chuang; Rong-Kuo Lyu; Shih-Ming Jung; Chang Gung Memorial Hospital

Background: Neuroma is a physiological response after a peripheral nerve repair. It contains a great quantity of wasted nerve fibers. Recycling these aberrant axons before neuroma formation seems a promising way basing on the theory of neurotropism. The goal of this study was to determine if the laterally-sprouting axons from the repaired site of a major peripheral nerve could be an adequate motor source for functioning free muscle transfer (FFMT).

Materials and Methods: 35 two-month-old S-D rats were separated into four groups. Group A (20 rats) underwent a cut-and-repair of the left median nerve (MN) at axillary area. And then 1.5mm behind the repaired site of MN attached the distal part of the transected musculocutaneous nerve (MCN) (Fig. I). The biceps muscle was thus sim- ulated as a FFMT and intended guiding those aberrant axons from MN for re-innervation. Group B (5 rats) underwent the same procedures with group A except the transected MCN was repaired directly. In group C (5 rats), the distal end of transected MCN was connected to the intact MN with end-to-side fashion. Group D (5 rats) underwent the same procedures with group A except the distal end of the transected MCN was buried back into biceps without re-innerva- tion. 4 months later, the animals were subjected to electrophysiological tests (Fig. II), sacrificed, and the nerves and muscles were taken for histological exam- ination.

Results: Obvious elbow flexion and adequate biceps contraction were observed on group A and B. Biceps atrophy and loss of elbow flexion were noted in group C and D. The average recovery ratio (RR) of biceps in muscle mass and contractile force were 91.38% and 71.29% in group A. Histological study confirmed the growth of nerve fibers from MN to MCN did happen in group A. No significant difference in the RR of flexor digitorum superficialis (FDS) was found between the experimental and control groups.

Conclusion: Our findings reveal the possibility to use the aberrant axons from the repaired site of nerve. Our design functionally re-innervates the biceps without interrupt- ing the recovery of muscles innervated by MN originally. It suggests that the repaired site of an injured peripheral major nerve could be an alternative motor source to innervate functioning free muscle transplantation.

The Effect of VEGF Gene Therapy and Hyaluronic Acid Enriched Microenvironment on Peripheral Nerve Regeneration Institution where the work was prepared: Gulhane Military Medical Academy, Ankara, Turkey fatih Zor; Mustafa Deveci; Abdullah Kilic; Fatih Ozdag; Bulent Kurt; Serdar Ozturk; Mustafa Sengezer; Gulhane Military Medical Academy

Despite the fact that the surgical techniques have reached a plateau, the functional results of nerve regeneration are still not satisfying. In this study the effect of VEGF gene therapy and HA enriched microenvironment on nerve regeneration is investigated. Thirty-two male Sprague-Dawley rats weighting between 250- 300 gr were divided into four groups, 8 rats in each. Group I: After coaptation no treatment regimens were used in this group. Group II: Following the coap- tation, hyaluronic acid film sheath is administered. Group III: Following the coaptation, VEGF gene therapy is performed. Group IV: Both the VGEF gene ther- apy and HA administration was performed. In order to show the VEGF gene expression, the mRNA of the VEGF gene was detected by RT-PCR technique. Electrophysiologic evaluation of the rats was performed at the 4th week. Intraneural scar formation and myelinated axonal counts were obtained histopatho- logically. Data was collected in SPSS and statistically analysed using Wilcoxon, Mann-Whitney U and Kruskall Wallis tests. RT-PCR studies indicated that the gene is incorporated to the host muscle cell and began to secrete VEGF. Electrophysiologic studies showed a significant difference between group I and the groups II, III and IV (p<0.05, p<0.05 and 0<0.01, respectively). The difference between group IV and groups II and III were statistically significant (p<0.05). The amount of scar formation was significant between the groups, which were treated with HA (groups II and IV) and the ones, which were not treated with HA (groups I and III), (p<0.05). Myelinated axonal counts was higher in group II, III and IV had when compared to group I (p<0.05, p<0.05, and p<0.01 respec- tively). The statistical analysis showed that combined therapy had better results. VEGF is thought to be the ideal growth factor to be used in nerve regenera- tion process. It has not only a neurogenic and angiogenic effect but also an autocrine and/or paracrine effect on regenerating nerve cells. Treatment with VEGF has induced the cellular phase of the nerve regeneration. HA has a district effect to control scar formation and important role on cell-to-cell interactions on regenerating nerves. By the combination of these two applications, both the cellular and the non-cellular phases of the nerve regeneration may be induced and more successful results may be obtained. The results are also encouraging for clinical applications of HA film sheath and VEGF gene therapy.

165 Four Dimensional CT-Scan Analysis of the Anterolateral Thigh Flap Perforator Branching Pattern Institution where the work was prepared: UT Southwestern Medical Center, Dallas, TX, USA Michel Saint-Cyr, MD1; Gary Arbique, PhD1; Jean Gao, PhD2; Dan Hatef, MD1; Spencer Brown, PhD1; Rod Rohrich, MD1; (1)UT Southwestern Medical Center at Dallas, (2)University of Texas, Arlington

Introduction: The vast majority of ALT flap anatomical vascular studies in the past have utilized lead oxide injections followed by 2-dimension radiography to determine vascular territories. Although lead oxide treated specimens provide excellent images, limitations of this methodology are well known. Three-dimension radiog- raphy can provide not only qualitative data on vascular anatomy, but also information on the direction and location of blood flow within each layer of a per- forator flap. Indeed to date, no studies have examined three and four dimensional vascular anatomies of the anterolateral thigh flap

Purpose: The goals of this study were two fold. First, to assess the static and dynamic vascular anatomy and branching pattern of the ALT perforator unit and second- ly, to establish a new comprehensive system of classifying the vascular branching patterns of the ALT perforator complex.

Materials and Methods: Ten fresh cadaver ALT flaps were dissected suprafascially, based on the largest perforator originating from descending branch of the lateral femoral cutaneous artery. We then performed dynamic and static CT scans of all ALT flaps using a GE Light Speed 16 slice scanner. For dynamic scans, a slow injection using a Harvard pump was used to introduce of 5 ml iodinated contrast agent over a 10 min period. During the injection, helical scans were repeated at intervals to volume image the time evolution of flap vascularity. Scans were performed at 80 kVp when using iodinated contrast agent to optimize contrast, and 120 kVp was used for lead oxide contrast to minimized beam hardening artifact.

Results: The main ALT perforator originated from the descending branch of the lateral femoral cutaneous artery in all flap dissections and nine of ten perforators were of the musculocutaneous variety. The ALT perforator unit vascular branching pattern was found to be highly variable and condensed throughout all layers of the flap with numerous vertical, oblique and horizontal vascular interconnections. Vascular communications between the fascial, adipose and dermal layers of the flap were observed up to the periphery of the flap in all cases and were maximized within a 5 cm radius of the perforator entry within the flap.

Conclusion: The ALT perforator unit branching pattern consists of a highly condensed network of direct and indirect branches linking the fascial, adipose and cutaneous com- ponents of the flap. This in turn provides additional insight in the possibility of safely harvesting large multi-component ALT flaps based on a single perforator.

The Supero-lateral Leg (SLL) Flap: an Anatomical Study and Clinical Applications Institution where the work was prepared: University of Sao Paulo, Sao Paulo, Brazil hsiang wei Teng; Luciano Ruiz Torres; arnaldo valdir zumiotti; University of Sao Paulo

The author performed an anatomical study of the proximal and lateral aspect of the leg, consisting of cadaver dissection, arteriogram and Doppler mapping, in order to disclose the features of a new vessel, denominated superior peroneal artery. It originates from the tibiofibular trunk in 70 % of times, from the per- oneal artery, 20%, and from the anterior tibial artery, 10%. It contributes to nourish the soleous and the lateral gastrocnemius muscle. The superior peroneal vessels are also suitable for microanastomosis. Therefore, the flap derived from the superior peroneal artery, called superolateral leg flap (SLL), was used for lower leg reconstructions in 10 patients, in two of them as chimeric flap for complex tridimensional defects, with good results.

Clinica Application of the Free Microdissected Thin Groin Flap Institution where the work was prepared: Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Kanagawa, Japan Naohiro Kimura, MD, PhD; Fujigaoka Hospital, Showa University School of Medicine

A free thin flap is a very convenient tool for reconstructive surgery, especially for the reconstruction of the extremities and treatment for burn scar contracture. In 2000, I developed a new method of preparing a thin flap by a microdissection, which represents intra-adiopsal dissection of the perforator vessel under operative microscopic magnification. Through this procedure, four kinds of thin perforator flaps could have been elevated accurately in a single step procedure: microdis- sected thin anterolateral thigh perforator flap, tensor fasciae latae perforator flap, deep inferior epigastric artery perforator flap, and thoracodorsal artery perfora- tor flap. Furthermore, I have applied the microdissection technique to the groin flap and succeeded in elevating microdissected thin groin flaps. From October of 2002 to March of 2006, 21 patients underwent reconstruction with microdissected thin groin flaps. In the preparation of the flap, the perforator penetrating the fascia of the sartorius muscle is initially detected suprafascially, and then the deep adipose and subfascia layer of the inguinal area is dissected using an operative microscope. After confirming the distribution of the blood vessels in this area, the flap was elevated while dissecting between the deep and superficial adipose layer. The flaps ranged from 8 to 22 cm in length and from 5 to 14 cm in width. Major complications were not observed except for postoperative venous thrombosis in one case, and the deep branch was absent in another case. Necrosis in a small part of the flap occurred in three cases. Other transfers were uneventful. The aver- age length of the pedicle was approximately 7 cm. There were some report of modification in groin flap elevation, the trial for thinning of the whole flap was far from successful, because the massive adipose tissue around the pedicle was left intact. However, the use of microdissection has allowed the buried vessel in the adipose tissue to be used as a pedicle of the flap, and to transfer a uniformly thin groin flap without excess fat mass.

166 Long-Term Follow-up of Total Penile Reconstruction with Sensate Osteocutaneous Free Fibula Flap in 23 Biological Male Patients Institution where the work was prepared: Gulhane Military Medical Academy. Depart. of Plastic Surgery, Ankara, Turkey mustafa Sengezer, Professor; serdar ozturk; mustafa deveci; fatih zor; Gulhane Military Medical Academy

PURPOSE: Surgical reconstruction of the penis is challenging because of the many cosmetic and functional (e.g., sexual intercourse and voiding) requirements that must be addressed.

MATERIALS & METHODS: Since 1994, 23 biologically male patients with total penile losses for various reasons were treated with free sensate osteocutaneous fibula flaps. The ages of the patients ranged between 20 and 27 years (mean, 23.2 years). The average follow-up period was 7.2 years (range, 1 to 12 years). Patient satisfaction was evaluated by a questionnaire regarding both quality of orgasm and daily activities. Conventional radiographic imaging, magnetic resonance imaging, and bone mineral densitometry were performed to evaluate the fate of the bony component. Sensibility was evaluated by bulbocavernous reflex and penile somatosen- sory evoked potentials.

RESULTS: Eight patients married, and six of them had eight children. Most patients and their partners reported pleasurable sexual intercourse and orgasm. Conventional radiographs of the fibular bone in neophalluses showed robust, calcified bone structure without any evidence of bone resorption or fracture. The magnetic res- onance images showed the cortical substance and spongiosum of the bone marrow, which are characteristic signs of bone viability. Viability of neophallus bone was shown even at 11-year follow-up (the longest follow-up in the literature). Dual energy x-ray absorptiometry measurements of the penile bone grafts showed that fibular components in the penis had bone mineral density values that were close to the normal subjects.These results were considered as evidence of via- bility of bone grafts. Neural integrity was found between the nerves of the neophallus and the residual penile bodies.

CONCLUSIONS: Free sensate fibula flap phalloplasty provides the cosmetic and functional requirements that an ideal penis should have. All results put an end to the discus- sion that the fibular component of the neophallus could resorb. Constitution of neural integrity is important in terms of pleasurable sexual intercourse.

Adult and Children Total Phalloplasty Institution where the work was prepared: Clinical Center of Serbia, Belgrade, Serbia and Montenegro Marko Bumbasirevic, MD, PhD1; Miroslav Djordjevic, MD, PhD2; Sava Perovic, MD, PhD2; (1)Belgrade University Clinical Center, (2)Clinical Center of Serbia

Introduction: Phalloplasty is a surgical project posing considerable challenges. There are many alternatives to this procedure (groin flap, forearm flap, rectus abdominis flap, fibula flap, latissimus dorsi flap). Our preference is latissimus dorsi flap because of good size of the neophallus.

Methods: From April 2001 till October 2005 total phalloplasty was performed on 23 patients aged between 10 - 46 years. Indications were failed epispadias repair (6), micropenis (4), intersexuality (1) and female transgenderism (12). A musculocutaneous latissimus dorsi free flap was harvested with thoracodorsal artery, vein and nerve. The flap was transferred to the pubic region and anastomozed to the femoral artery, saphenous vein and ilioinguinal nerve. Two-staged urethro- plasty was performed in all patients using buccal mucosa, except three when a Mitrofanoff channel had been created previously. Penile prosthesis, either semi- rigid (7) or inflatable (8) was implanted, in two cases after puberty. Cylinders were covered with vascular prostheses that imitate tunica albuginea and addi- tionally fixed to the periostium of the inferior pubic rami.

Results: Follow-up was from 6 to 59 months (mean 29). Penile size varied from 13 to 17 cm in length and from 10 to 12 cm in circumference. No flap necrosis, nei- ther partial nor total, was noted. Urethral fistula was occurred in 4 patients and repaired six months later. The donor site healed acceptably in 17 cases while in the remaining 6 moderate scar occurred. Penile prostheses function is satisfactory. Conclusion: Musculocutaneous latissimus dorsi flap presents good alter- native for phalloplasty that enables neophallic size as in adults.

Lymph Node Transfer for Treating Mild to Moderate Lymphoedama Institution where the work was prepared: E-Da Hospital, Kaohsiung, Taiwan Victoria Rose, MBBS, MD, FRCSpl; Guan-Ming Feng; Samir Mardinis; Hung-Chi Chen; E-Da Hospital

There are many options for treating limb lymphoedema however the various modalities each have specific limitations. Lymph node transfer has been shown to reduce the frequency of cellulitis in animal models. This study attempted to evaluate the efficacy of this treatment option in a clinical setting. During a 2 year period 15 patients with mild to moderate lymphoedema underwent lymph node transfer. All patients were assessed prospectively. After a 3 year follow-up, average reduction in skin tonacity was 47.46% (range 17.85 to 87.76%) and average reduction in limb circumference was 50.28% (range 33.68 to 69.44%). Those with upper limb involvement experienced both better results for reduction in skin tonacity and limb circumference compared to those with lower limb involvement.

167 Microdialysis is a Reliable Tool for Surveillance of Free Muscle Flaps Institution where the work was prepared: Department of Plastic Surgery, Aarhus, Denmark Hanne Birke Sørensen; Gete Toft; Jens Bengaard; Aarhus University Hospital

Introduction: Microdialysis has been the standard procedure for surveillance of all free flaps at our Department of Plastic Surgery since 1998. We here present our experi- ence regarding reliability of this monitoring method in free muscle flaps.

Background: Microdialysis is a technique for continuously observation of tissue metabolism by minimally invasive probes placed in the tissue. Glucose and lactate are the main metabolites of interest when monitoring tissue perfusion.

Methods: Sixty-eight free muscle flaps were included in this study. All muscle flaps were applied for reconstruction after trauma or tumor resection. A microdialysis catheter (CMA60) with a 30 mm long and 1 mm wide semi permeable membrane was placed in the free muscle flap after revascularization. Another catheter was placed in subcutaneous tissue not operated on for reference. The dialysate leaving the catheters was collected in small vials and analyzed for contents of metabolic parameters. A new ischemic marker with indication of tissue supply of oxygen as well as glucose was made by combining the lactate and the glu- cose concentrations in a lactate/glucose ratio.

Results: Nine muscle flaps were diagnosed ischemic using the concentration of the metabolites (Isc-group, n=9). Of those nine flaps, five flaps were revascularized. The remaining four flaps were lost, due to absence of functioning recipient vessels. Fifty-one free muscle flaps were uncomplicated without any sort of salvage procedure needed after surgery (Unc-group, n=51). In the remaining eight cases surgical or non-surgical intervention was performed post-operatively (Com- group, n=8). The need of intervention was based on either deteriorating clinical signs or a tendency in the metabolic parameters signifying inadequate flap perfusion. Continuously decreasing glucose and/or increasing lactate concentration was used as indicator of compromised flap perfusion. All eight flaps sur- vived 100% without need of new surgical revascularization. The minimum glucose concentration measured in each flap was: Isc-group: 0.00 – 0.20µmol/l, Com-group: 0.09 – 3.89µmol/l, and Unc-group: 0.49 – 6.78µmol/l. The maximum lactate concentration measured in each flap was: Isc-group: 14.23 – 48.87µmol/l, Com-group: 8.40 – 20.69µmol/l, and Unc-group: 3.25 – 20.50µmol/l. The maximum lactate/glucose ratios calculated in each flap was: Isc-group: 182.94 – 160 377.35, Com-group: 2.17 – 138.82, and Unc-group: 0.65 – 14.89. The lactate/glucose ratio has a sensitivity and specificity of 100% with respect to critical ischemia.

Conclusions: We have in this study demonstrated that microdialysis is a reliable tool for surveillance of free muscle flaps. We recommend that reoperation is performed if the lactate/glucose ratio exceeds 150 in a free muscle flap.

168 ASRM Concurrent Scientific Paper Presentations C-2

A New Concept of Cell-Based Immunotherapy with Chimeric Cells for Acceptance of Composite Tissue Allograft Transplants Institution where the work was prepared: The Cleveland Clinic Foundation, Cleveland, OH, USA Maria Siemionow, MD, PhD; Aleksandra Klimczak; Yalcin Kulahci; Galip Agaoglu; Anna Jankowska; The Cleveland Clinic Foundation Purpose: In search for strategies replacing life-long immunosuppression cellular therapeutics become a new alternative for solid organ transplants. This study was designed to evaluate the efficacy of adoptive transfer of donor-specific chimeric cells, originating from two different MHC mismatched donors in engraftment and immunotherapeutic effect of composite tissue transplants acceptance. Methods: Thirty three trimeras (11 primary and 22 secondary) were created across MHC barrier. First, primary trimeras (n=9) were created via intraosseous bone marrow transplantation of 70x106 cells from LBN(RT1n) and ACI(RT1a) donors to the same LEW(RT1l) recipients. Next, secondary trimeras (n=22) were created via adoptive transfer of MACS-sorted: double positive RT1n/RT1a (9x106-24x106), and single positive RT1n (4.5x106-9.0x106) and RT1a (6.0x106-12.0x106) cells from primary trimeras into the bone of naïve recipients. Eight secondary trimeras served as controls without treatment, 14 trimeras received 7-day protocol of ·‚-TCR/CsA therapy. Efficacy of MACS-sorting and donor chimerism (for MHC class I antigens) was assessed by flow cytometry. At day 21 after secondary trimera creation, the therapeutic effect of adoptive transfer was tested by bilateral transplantation of skin allografts from the LBN and ACI donors. Immunofluorescence assessed the presence of donor cells in the lymphoid organs of recipients. Results: In primary trimeras 13.1% of LBN donor positive cells (RT1n) and 6.8% of ACI donor positive cell (RT1a) was found. MACS-sorting revealed 87% - 96% puri- ty for double positive RT1n/RT1a cells. At day 21 secondary trimeras created via transplantation of double positive cell (RT1n/RT1a) revealed 8.3% of RT1n and 11.3% of RT1a positive cells. Transfer of single positive cells induced chimerism of 6.0% for RT1n and 7.6% for RT1a Non treatment trimeras rejected transplanted flaps within 11 to 18 days. Prolonged skin flap survival was achieved up to 120 days after transplantation of double positive RT1n/RT1a cells and for over 200 days in recipients receiving single positive RT1n and RT1a chimeric cells (still under observation). Presence of chimeric cells in the spleen, lymph nodes and thymus of recipients confirmed engraftment of cells from two different donors into lymphoid organs of recipients. Conclusions: Intraosseous transplantation of bone marrow cells from two different MHC mismatched donors resulted in creation of donor-specific trimera. Isolation and adoptive transfer of chimeric cells proved to be efficacious in engraftment and chimerism induction in naïve donors leading to extension of vascularized skin allograft survival. This new strategy of cell-based immunotherapy may have direct application in clinical transfer for solid organ and CTA transplants.

Intrajejunal Administration of Fresh Donor Splenocytes Significantly Delays the Onset of Rejection of Heterotopic Hindlimb Composite Tissue Allotransplants in Rats Institution where the work was prepared: Department of Plastic Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan Christopher Glenn Wallace, MB, ChB, MRCS; Chia-Hung Yen, PhD; Hsiang-Chen Yang, MSc; Chun-Yen Lin, MD, PhD; Ren-Chin Wu, MD; Wei-Chao Huang, MD, PhD; Fu- Chan Wei, MD, FACS; Chang Gung Memorial Hospital, Chang Gung University and Medical College Antigen-specific oral/mucosal tolerance has benefited allograft survival in several animal models; jejunal mucosal tolerance was recently shown to be superiorly tolerogenic for rat car- diac allotransplants. Therefore, it was investigated whether intrajejunal (IJ) administration of fresh donor splenocytes (FDS) could delay semi-allogeneic hindlimb CTA rejection. Methodology: Adult (8-10 weeks) age-/sex-matched recipient Lewis (LEW; RT1l) and donor Lewis-Brown-Norway (LBN; RT1l+n) rats were used. Five recipient Groups were investigated: “SHAM” (n=12), “TREATED” (n=12), “SHAM/CTA” (n=5), “TREATED/CTA” (n=8) and “ISO” (isogeneic hindlimb transplants; n=5). Percutaneous gastro-duodeno-jejunostomies were sited in all rats in the first four Groups on Day -12 via midline laparotomies. SHAM and TREATED rats were sacrificed on Day 0 for in vitro mixed lymphocyte reaction (MLR). SHAM/CTA and TREATED/CTA instead received heterotopic LBN hindlimb CTAs on Day 0. TREATED and SHAM received IJ-FDS (5x107 cells) or vehicle alone, respectively, everyday on Days -9 through -3. TREATED/CTA and SHAM/CTA received IJ-FDS (5x107 cells) or vehicle alone, respectively, everyday from Day -9 until completion of rejection. Immunosuppressive drugs were never administered. CTAs were monitored for onset and completion of rejection (using published definitions). Recipient CTA-muscle and CTA-skin were biopsied on Day +7. Results: In vitro MLR (Figure): Proliferation of SHAM Group splenocytes against LBN stimulation was significantly greater than that of TREATED splenocytes against LBN stimulation (p<0.01), SHAM splenocytes alone (p<0.001), and TREATED splenocytes alone (p<0.001); proliferation, however, was similar in each of the latter three groups (p>0.05). Conclavulin A was equally stimulatory (>15-fold) for both SHAM and TREATED splenocytes (p>0.05). Transplant survival: Onset of rejection was significantly delayed by IJ-FDS administration (p<0.0005; TREATED/CTA mean 9.6 days; SHAM/CTA mean 6.0 days), however completion of rejection was not (TREATED/CTA mean 14.1 days; SHAM/CTA mean 13.5 days). ISO transplants survived indefinitely. Histology (Figure): CTA-skin and CTA- muscle biopsies from SHAM/CTA rats showed severe inflammatory cellular infiltrates and moderate oedematous changes; skin additionally showed moderate focal epidermal necrosis. These features were mild, or absent, in TREATED/CTA biopsies. ELISA: Gamma-interferon levels were reduced (by 7-fold; p<0.01) in MLR supernatants of TREATED compared to SHAM Groups. Conclusion: Treatment with IJ-FDS induced a favourable environment for CTA acceptance that conferred resistance to onset of rejection, without concomitant use of immunosup- pressants. This resistance did not persist despite prolonged IJ-FDS administration. Further investigations are underway to delineate molecular and cellular mechanisms underlying this resistance. IJ donor antigen administration may be a useful adjunctive method to boost peripheral mechanisms in CTA tolerance induction regimens.

169 Perfusing with Anti-alpha-beta-T Cell Receptor Monoclonal Antibody in Composite Osteomyocutaneous Tissue Allotransplantation Avoids Graft-versus-Host Disease in the Lethally Irradiated Recipient Rats Institution where the work was prepared: Chung Rong Ho, Tao-yuan, Taiwan Chung-Rong Ho, MD; Wei-Chao Huang, MD; Jeng-Yee Lin; Nai-Jen Chang; Yu-Hsuan Hsieh; Fu-Chan Wei; Chang Gung Memorial Hospital

Introduction: Graft-versus-host disease (GvHD) can be a major hazard to the recipient in composite tissue allotransplantation (CTA). Lymphadenectomy and irradiation of the allotransplants have been used to reduce the severity of GvHD. This study is to develop an alternative method to prevent the occurrence of GvHD by uti- lizing graft perfusion with anti-alpha-beta-T cell receptor monoclonal antibody (anti-alpha-beta-TCR mab) and manipulating the bone graft of CTA in the lethally irradiated recipient rats.

Materials and Methods: Male (6- to 8-week old) donor Brown Norway (BN, RT1Ac) and (10- to 12-week old) recipient Lewis (RT1Al) rats weighing between 220 and 300g were used. Lewis rats were preconditioned with 950 cGy total body irradiation (TBI) on Day-1. Osteomyocutaneous (OMC) flap weighted around 10±2.4g from the hindlimbs were transplanted on Day0. No immunosuppressant was used. The experiment was grouped as shown in table1. In the study group (group4), the medullary cavity of the bone was flushed with 10cc heparinized normal saline and curettaged with 22 gauge needle to remove bone marrow cells and then perfused with pure 1mg anti-alpha-beta-TCR mab and 9cc normal saline via artery of the pedicle after flap harvest and before transplantation. Body weight was checked weekly. Chimerism level was assessed by flow cytometry on 15, 30, 60, 90, 120, and 150 days after flap transplantation. Sections of the auricle and the graft skin were taken for pathology on Day18. In vitro T-cell responses were evaluated by mixed lymphocyte reactivity assays.

Results: All of the rats in group 1 died within 12 days. Syngeneic and allogeneic hindlimb OMC flap could prolong the life of the recipient rats after lethal irradiation. The allogeneic hindlimb OMC flap transplantion group (group3) developed GvHD, and animal died around 3 weeks. The average of chimerism level in group 3 and group 4 were 98.85% and 99.77%. In contrast to group 3, the group 4 had 83% long term survival of the allotransplants and the animals didn't lose body weight (Figure1). The flow cytometry showed engraftment of the donor hematopoietic cell with reconstitution of multilineaged hematolymphoid cells (Figure2). In vitro mixed lymphocyte reaction assay in group 4 showed hypo-responsiveness to donor antigen, but hyper-responsiveness to third-party antigen.

Conclusion: Allogeneic OMC flap transplantation could induce GvHD in the recipients with full myeloablative conditioning. GvHD can be prevented by the flap with anti- alpha-beta-TCR mab perfusion and manipulation the bone graft. This immunomodulation can successfully induce donor-specific tolerance to CTA.

Fludarabine Facilitates the Nonmyeloablative Strategy and Creation of Mixed Chimerism to Induce Immune Tolerance to Composite Tissue Allograft Institution where the work was prepared: Chang Gung Memorial Hospital, Tayoyuan, Taiwan Jeng-Yee Lin, MD; Wei-Chao Huang; Chung-Rong Ho; Fu-Chan Wei; David CC Chuang; Ming-Huei Cheng; Chang Gung Memorial Hospital

Background: It has been proved that tolerance induction to composite tissue allotransplantation (CTA) through mixed allogeneic chimerism (MAC) is feasible in rats. Bone marrow transplantation (BMT) to create MAC inevitably involves total body irradiation (TBI) for successful engraftment. However, TBI-based strategy for CTA can not be justified clinically. Fludarabine can suppress lymphocyte proliferation and has been reported to reduce TBI doseage necessary for BMT engraftment. The purpose of this study is to investigate if fludarabine can facilitate MAC to induce immune tolerance in rat CTA model with low-dose TBI. Materials and

Methods: Thirty male (8-to 10-week old) Lewis rats (RTA1l) were equally categorized into 6 groups as recipients. Male Brown Norway (BN) rats (8-to-10 week old RTA1c) were the donors. Recipients were irradiated with different dosages of TBI one day before BMT. Group I: 950 cGy; Group II: 600 cGy; Group III: 400 cGy; Group IV: 200cGy; Group V: 400 cGy plus fludarabine (50mg/kg), intraperitoneally (IP); Group VI: 200 cGy plus fludarabine, IP. The recipients from group II to VI were treated with one dose of 5 mg antilymphocyte serum (ALS), one day before BMT, cyclosporine 16 mg/kg/d from days 0 to 10 and one dose of 5 mg ALS, 10 days after BMT. Recipients were transplanted with 100 x 10^6 bone marrow (BM) cells with alpha beta-TCR+ and gamma delta-TCR+ T-cell depletion (TCD). A hindlimb osteomyocutaneous flap allotransplantation (BN to MAC rat) were performed 28 days after BMT. The level of chimerism and multilineage were assessed by flowcytometry 28 days after BMT and 15, 30, 60, 120, and 150 days following CTA. Rejection and graft versus host disease (GVHD) were exam- ined clinically and pathologically. In vitro T proliferation was assessed by mixed lymphocyte reaction assay 150 days after CTA.

Results: Recipients in all groups were 100 % engrafted with donor BM. The level of chimerism in each group 28 days after BMT were: Group I: 98%; Group II:81 %; Group III: 49.7 %; Group IV: 27%; Group V: 51.2%; Group VI: 41%. GVHD didn't occur after BMT with TCD, but its incidence after CTA increased with the increasing TBI doseage . Graft acceptance rate (without GVHD) were: Group II:100%; Group III: 80%; Group IV: 20%; Group V:80%; Group VI.:60%.

Conclusion: Partial conditioning and BMT with TCD can successfully create MAC to achieve immune tolerance in rats. Addition of fludarabine in the immunosuppression regimen significantly increases MAC and graft tolerance rate.

170 Rapamycin-Treated Alloantigen-Pulsed Host Dendritic Cells for the Induction of Hind-Limb Allograft Survival Institution where the work was prepared: University of Pittsburgh Medical Center, Pittsburgh, PA, USA Justin Michael Sacks, MD; Ryosuke Ikeguchi; Jignesh Unadkat; Elaine Horibe; Linda Lu; W.P. Andrew Lee; Maryam Feili-Hariri; University of Pittsburgh Medical Center

Introduction: Risks of chronic immunosuppression hinder composite tissue allograft (CTA) transplantation such as face and hand. Chronic immunosuppressive therapy can ultimately lead to side effects such as malignancy, opportunistic infections and organ toxicity. Thus, novel approaches to induce immunological tolerance for the treatment of graft rejection holds considerable promise. We have assessed whether rapamycin (Rapa)-generated GM-CSF dendritic cells (DC) can induce long-term (>100 day) survival in a CTA animal model.

Methods: DC were derived from bone-marrow cells cultured in GM-CSF with rapamycin (Rapa-DC) or in GM-CSF (GM-DC). DC phenotype and function were examined. Orthotopic hind-limb transplantations were performed (day 0) from Wistar-Furth to Lewis rats. Controls included (n=6/group): untreated, cyclosporine A (CsA 10mg/kg, day 0-20), and anti-lymphocyte serum (ALS, day -4,+1 with CsA). Experimental groups included (n=6/group) CsA+ALS combined with GM-DC or Rapa-DC pulsed with or without donor antigen (Ag) (5 x 106 cells, day +7, +14). Epidermolysis/desquamation of donor skin defined rejection. Recipient's peripheral blood mononuclear cells were examined for production of pro- and anti-inflammatory cytokines on day 30, 50, and 100 upon Ag restimulation. Biopsies were performed on day 21 and at rejection.

Results: Donor alloAg-pulsed GM-Rapa-DC significantly prolonged median survival time (95.5 days) compared to GM-Rapa-DC (46.0 days) and controls (p<0.05). Allograft survival >100 d was observed (3/6 rats) in alloAg-pulsed GM-Rapa-DC group. Rapa inhibited DC maturation. Pulsing DC with donor cell antigens did not change DC phenotype and function. T cells from donor Ag-pulsed Rapa-DC-treated group produced more IL-10 and less IFN-gamma following donor and third-party antigenic challenge or via TCR activation in vitro.

Conclusions: Our data suggest that donor Ag-pulsed host Rapa-DC combined with transient immunosuppression induce CTA survival across a full MHC barrier. This repre- sents a basis for a clinically applicable strategy to achieve CTA survival with reduced systemic immunosuppression.

Size Limits in Autologous Cell-based Ectopic Prefabrication of Engineered Bone Flaps in Rabbits Institution where the work was prepared: University Hospital Basel, Basel, Switzerland Oliver Scheufler, MD1; Dirk J. Schaefer, MD1; Claude Jaquiery, MD1; Alessandra Braccini, PhD1; David J. Wendt, PhD1; Juerg A. Gasser, PhD2; Peter Ingold, PhD2; Gerhard Pierer, MD, PhD1; Michael Heberer, MD, PhD1; Ivan Martin, PhD1; (1)University Hospital Basel, (2)Novartis Institutes for Biomedical Research

Introduction: Autologous bone flaps are the gold standard in reconstruction of large bone defects but limited by availability and donor site morbidity. We generated large ectopic bone flaps in rabbits combining flap prefabrication and bone tissue engineering concepts. We then aimed at determining size limits regarding the depth of tissue ingrowth and bone tissue formation within the flaps.

Methods: Porous hydroxyapatite scaffolds (80±3% porosity, Fin-Ceramica, Faenza, Italy) were fabricated in the shape (i) of small disks (4mm height, 8mm diameter), used to validate the osteogenic capacity of rabbit BMSC in vivo, and (ii) of tapered cylinders (30mm height, 20mm upper base diameter, 10mm lower base diame- ter), used to determine tissue ingrowth and bone tissue formation at different construct diameters. Expanded bone marrow stromal cells (BMSC) from 12 NZW rabbits were uniformly seeded into disks and tapered cylinders at a density of 10 x 106 cells per cm3 of scaffold by continuous perfusion in alternate direc- tions through the scaffold pores at a velocity of 1.2 ml/min. for 24 hours in a perfusion bioreactor. In each animal, a disk loaded with autologous BMSC (group 1) and a cell-free disk (group 2) were implanted subcutaneously. Two tapered cylinders loaded with autologous BMSC, wrapped in a panniculus carnosus flap and covered by a semipermeable membrane (vascularized condition; group 3) or covered by a semipermeable membrane and inserted under the panniculus carnosus (non-vascularized condition; group 4) were implanted on opposite sides. Constructs were explanted after 12 weeks and assessed by MRI, µCT and histology.

Results: Uniform bone formation was observed in cell-seeded disks (group 1), whereas no bone formed in cell-free disks (group 2). In tapered cylinders, constructs were filled by connective tissue in the outer 4.2±0.3 mm and contained bone tissue in the outer 2.5±0.3 mm in vascularized conditions (group 3), whereas no con- nective or bone tissue formed under non-vascularized conditions (group 4), resulting in significant differences in all assessed histomorphometric parameters.

Conclusions: A panniculus carnosus flap supported ectopic prefabrication of large engineered bone flaps in rabbits. The finding that bone tissue was restricted to the outer region of the flaps could be explained by insufficient vascularization of the central core of the constructs upon implantation and prompts for the development of strategies to improve vessel ingrowth from the flap.

171 Inside-Out Tissue Engineering: Using Explanted Microcirculatory Beds for Generating Vascularized Neo-Livers Institution where the work was prepared: Stanford University, Stanford, CA, USA Robert G. Bonillas, MD1; Cynthia Hamou1; Daniel J. Ceradini, MD2; Shahram Aarabi1; Geoffrey Gurtner1; (1)Stanford University, (2)New York University

Introduction: Organ level tissue engineering is limited by the incorporation of a functional microvasculature and a reliable means for re-integration into the host circulation. Our laboratory has described a technique using autologous explanted microcirculatory beds (EMBs) or free flaps as bio-scaffolds for engineering complex 3- dimensional constructs via their intact microvasculature. Here we investigated whether vascularized neo-livers could be generated with differentiated progen- itor cells (MSCs and MAPCs) or hepatocytes using this system.

Methods: Superficial inferior epigastric EMBs (n=30) were explanted from rats and maintained ex vivo in a perfusion bioreactor system. 4.0x10^6 partially differentiated progenitor cells (pMSCs or pMAPCs) or hepatocytes were infused via the afferent artery during the prolonged (>12hrs) ex vivo cultivation. Seeded EMBs were replanted and harvested on post-replantation days 3, 7, 14 and 21. Seeding efficiency was determined by immunohistochemistry and FISH analysis, and pro- liferation by BrdU/Ki67 assays. Seeded cell fate was ascertained using real time RT-PCR and albumin staining.

Results: Progenitor cells and hepatocytes seeded ex vivo egressed in bulk from the microcirculation and formed BrdU+/Ki67+ proliferative clusters in the perivascular space following re-implantation. Seeded EMBs formed vascularized neo-livers which retained features up to 21 days following replantation. Both cell types remained localized to the EMB without evidence of re-homing or immunological reaction. Ongoing studies are determining the functional capacity of these neo-livers in replacing albumin levels in a rat model of analbuminemia.

Conclusion: Here we demonstrate the construction of vascularized neo-livers using progenitor/stem cells and EMBs. The abundance of autologous EMBs, the sustainabil- ity of them ex vivo, and the ability to seed them with large numbers of progenitor cells makes this "inside-out" tissue engineering paradigm attractive for gen- erating organ-level tissue constructs.

De Novo Bone Formation by Adult Adipose Derived Stem Cells in Prefabricated Vascularized Capsules in Rats Institution where the work was prepared: Southern Illinois University School of Medicine, Springfield, IL, USA Minh-Doan Nguyen, MD; Hans Suchy; Jagadish Hegde; Chris Chambers; Michael Neumeister; Southern Illinois University School of Medicine

Introduction: Bony defects of the extremities and the mandible secondary to trauma, tumor resection, or congenital deformity present significant morbidity for the patient, cost to society and a challenging problem for the reconstructive surgeon. Current practices are limited by the size of the defect that can be repaired, poor via- bility/functionality post-transplant and morbidity at the donor tissue site. An engineered tissue composed of osteoblast progenitors, a biocompatible scaffold and functional microvascular network could eliminate most, if not all, of the above mentioned complications. Initial results of this study demonstrate possible de novo bone formation from adipose derived stem cells (ADSC) in a calcium hydroxyapatite and alginate/collagen matrix.

Methods: Subcutaneous fibrovascular capsules were created in the inguinal region of adult male Lewis rats. ADSCs obtained from male Lewis rats were suspended in an alginate/collagen matrix or seeded in a calcium hydroxyapatite matrix and implanted into the prefabricated capsules with and without femoral bone fragments. X-ray images of the constructs were obtained for 6-12 weeks to monitor changes in bone density. At the end of each time point, the constructs were removed and histological analysis (H&E) was performed to identify bone formation.

Results: Radiographic analysis of the composite bone constructs by Faxitron demonstrated an increase in bone density over time. On histological examination, the ADSCs are viable and there seems to be focal areas of de novo bone formation.

Conclusions: Both radiographic and histological analysis of the composite bone constructs suggest that there is some de novo bone formation by ADSCs in the prefabricat- ed vascularized capsules. The osteoconductive environment provided by the biocompatible matrices and the osteoinductive factors provided from the bone marrow and osteogenic factors facilitate bone formation by implanted ADSCs.

172 Involvement of Notch1 in Osteoinduction of Adipose Derived Adult Stem Cells Institution where the work was prepared: Southern Illinois University, Springfield, IL, USA Damon Cooney, MD, PhD1; N. Berry2; Christopher Chambers3; MW Neumeister2; (1)Southern Illniois University School of Medicine, (2)SIU School of Medicine, (3)Southern Illinois University School of Medicine

Introduction: Complex reconstruction is one of the most challenging microsurgical scenarios. The principle of replacing “like with like” becomes more difficult the more spe- cialized or complex the tissue to be replaced is. The ideal situation would involve the prefabrication of an almost identical structure and then free tissue trans- fer to the site of reconstruction. One of the steps toward this goal is understanding of molecular mechanisms which control the differentiation of adipose derived adult stem cells (ADSCs) into the different tissues desired. Delineating these pathways in osteoinduction will allow the manipulation of bone forma- tion in order to construct compound prefabricated flaps for complex microsurgical reconstruction.

Methods: Rat ADSCs were induced with osteo-induction (OI) media. Bone matrix formation was assayed by Alizarin Red staining. Expression changes in Notch1, Runx2, and Jagged1 were determined using quantitative PCR. A constitutively active form of Notch1 was expressed in ADSCs by adenovirus infection. Human ADSC were obtained from lipo-aspirate and placed in OI media. Jagged1 expression was assayed by PCR and ERK activation by phosphorylation were determined by western blot.

Results: The results of the quantitative PCR experiments in Rat derived ADSC's indicate up-regulation of the levels of Notch1 and its ligand, Jagged1, which peak at 14 days after OI. In addition, the levels of Runx2, an osteogenic transcription regulator that is also involved in the Notch pathway is up regulated during the first few days of OI stimulation but then falls again. The importance of Notch1 signaling was shown by the increase of matrix deposition and Runx2 signal following the transfection of constitutively active Notch1 into the cells using an adenovirus vector. Finally, the presence of this pathway in human cells was established by the up regulation of Jagged1 and the activation of the ERK transcription cascade during OI of human adipose derived stem cells but with a dif- ferent time course than that seen in rat derived cells.

Conclusion: The importance of the Notch signaling pathway in osteoblast formation from stem cells has been shown by the up-regulation of Notch itself as well as its lig- and Jagged1 and downstream effectors Runx2 and ERK. This pathway appears to be important in human cells as well as rat although differences do exist. Better understanding of these pathways will result in the control of bone formation for tissue engineering and flap pre-fabrication.

In Vivo Down-Regulation of Vascular Endothelial Growth Factor (VEGF) Protein in a Gracilis Muscle Model Using siRNA Institution where the work was prepared: University of Nevada School of Medicine, Las Vegas, NV, NV, USA Peter Robert Letourneau, MD; Farhad A. Amiri; Linda L. Stephenson, BS, MT; Wei Z. Wang, MD; William A. Zamboni, MD; University of Nevada School of Medicine

Introduction: VEGF is an angiogenic protein that has been studied extensively for its role in benign and pathogenic angiogenesis. VEGF transcription and translation are up- regulated in response to hypoxia, and, paradoxically, also by hyperoxia. Small interference RNA (siRNA) interferes with gene expression by inhibiting transla- tion of protein. Most studies to date have examined the effects of siRNA in vitro, and do not address the problems of systemic administration of siRNA in an in vivo model. Studies that examine siRNA in vivo typically involve the use of methods that are either nonphysiologic, cause an immune response, or are not clinically applicable to humans (e.g., tail vein injection). The purpose of this study was to evaluate if a decrease in VEGF protein levels in skeletal muscle could be achieved in vivo, using a systemic route of administration of siRNA that is both clinically applicable and physiologic.

Methods: siRNA targeting VEGF mRNA was complexed with a linear polyethylenimine(PEI). Using a weight-based protocol, male Wistar rats were given a single intraperi- toneal injection of the siRNA-PEI complex. A gracilis muscle flap was raised with single vessel inflow and outflow. In a preliminary experiment, a 24-hour inter- val between injection and tissue harvest was found to provide maximal down-regulation of VEGF protein levels. Subsequent animals were injected 24 hours in advance with the siRNA-PEI complex; gracilis muscle was then harvested and analyzed for VEGF protein levels via Western Blot. Control consisted of ani- mals injected with a nonsilencing siRNA complexed with PEI. VEGF 164 and 120 protein levels were calculated based on a percentage of their respective pos- itive controls and expressed in nanograms. Results were analyzed using ANOVA, with a p value ? 0.05 accepted as significant.

Results: Maximal down-regulation of VEGF 164 protein levels in gracilis muscle occurred 24 hours after injection. VEGF 164 protein levels were decreased in the VEGF siRNA group by 69% compared to the nonsilencing siRNA group (p < 0.05). There was no statistically significant difference in VEGF 120 levels between the two groups. Conclusion: Small interference RNA can be safely and successfully delivered to distant targets such as skeletal muscle after systemic administra- tion, using intraperitoneal injection of siRNA complexed with a linear polyethylenimine. VEGF 164 levels in skeletal muscle can be down-regulated by almost 70% using this clinically applicable and physiologic route of administration. These data may be useful in future in vivo studies examining siRNA and/or the function of VEGF.

173 Effects of Hyperbaric Oxygen on the Survivability of the Replanted Hindlimb Subjected to Prolonged Warm Ischemia Institution where the work was prepared: William Beaumont Army Medical Center, El Paso, TX, USA Christopher J. Salgado, MD1; Juan A. Ortiz, MD2; Samir Mardini, MD3; Hung-Chi Chen, MD, FACS3; Raoul Gonzales, DVM2; James R. Little, MD4; (1)Cooper University Hospital / U.M.D.N.J. Robert Wood Johnson Medical School, (2)William Beaumont Army Medical Center, (3)E-da/I-I Shou University Hospital, (4)USAF Schoof fo Aerospace Medicine

Introduction: The purpose of this investigation was to evaluate the influence of hyperbaric oxygen (HBO) therapy on the survival of a replanted extremity subjected to pro- longed warm ischemia. Among the relative contraindications to replantation are prolonged warm ischemia time since an obstruction to blood reflow may occur in amputated parts that are subjected to more than 6 hours of warm ischemia. This inability to reperfuse the tissue has been termed the “no-reflow phenom- enon”. Muscle is the one tissue most susceptible to ischemia and begins to undergo irreversible changes after 6 hours at room temperature.

Material and Methods: Using a rat model, which is a well-established replantation model, twelve rat hindlimbs are amputated and subjected to four hours of normothermic ischemia. This time is equivalent to six hours in a human. The average weight of the animals was 532 grams and replantation of the hindlimb was performed by bone fixation followed by microvascular anastomosis of the femoral artery and vein using 11-0 suture. Limb revascularization was confirmed at the end of all pro- cedures by pulse oximetry recordings. Six animals served as a control group and no further therapy was instituted, whereas, the other six animals served as the study group and were subjected to HBO therapy for 90 min. at 2.5 ata in the postoperative period for three days. Postoperative evaluation consisted of daily pulse oximetry recordings of the replanted part and visual observation for signs of limb viability.

Results: Seven animals died during the replantation procedure and were not included in the evaluation. All animals were euthanized at seven days postoperatively if the limb was viable or earlier in cases of a non-viable limb. In the control group, 3 of 6 limbs (50%) were viable at postoperative day seven (pulse oximetry >92% and no signs of vasocongestion). In the study group, which was subjected to HBO therapy on the day immediately following the replantation proce- dure and three days postoperatively for 90 minutes at 2.5 ata, 5 of 6 limbs (83%) were viable at the end of the study period. The results were statistically sig- nificant

Conclusion: Although replantation of an amputated extremity after it has been subjected to six hours (prolonged ischemia) in a warm environment is considered a relative contraindication due to a poor outcome, our results show that more aggressive attempts at replantation are warranted if adjunctive hyperbaric oxygen thera- py can be employed in the postoperative period.

Efficacy of Intravenous and Intraosseous Donor Bone Marrow Transplantation in Chimerism Induction on Vascularized Skin Allograft Transplants Institution where the work was prepared: The Cleveland Clinic Foundation, Cleveland, OH, USA Aleksandra Klimczak, PhD; Sakir Unal; Maria Siemionow; The Cleveland Clinic Foundation Introduction: Vascularized skin allografts (VSA) can be used for coverage of large defects after burn and trauma injury. Due to high skin immunogenecity life-long immun- suppression is required procedure in routine use of VSA in clinical practice. We have investigated effect of 7-day protocol of ·‚-TCR and CsA therapy augment- ed with donor bone marrow transplantation (BMT) on chimerism induction and extension of VSA survival.

Materials and Methods: Twenty transplantations of VSA (groin flaps) across strong MHC barrier were performed between ACI(RT1a) donors and LEW(RT1l) recipients in 5 experimental groups (4 animals each). Intraosseous (i.o.) and intravenous (i.v.) BMT (70x106 cells) was given as a supportive therapy of 7-day ·‚-TCR/CsA protocol. Isografts (Group 1) received no treatment. Allografts Group 2 and Group 3 received only donor BMT given via i.v. and i.o. routes respectively. Allografts Groups 4 and 5 received 7-day protocol of ·‚ -TCR/CsA augmented with i.v. (Group 4) and i.o. (Group 5) donor BMT. Signs of VSA transplants rejection were evaluated daily. Modification of the immune system by immunodepletion of T-lymphocytes and therapeutic effect of donor BMT on donor chimerism induction was assessed by flow cytometry using mAb specific for donor MHC class I (RT1a) antigens. Immunostaining tested donor cells engraftment into lymphoid organs of recipients.

Results: Isografts survived indefinitely. VSA controls treated with BMT only rejected flaps within 11 and 14 days after i.v. and i.o. BMT respectively. Combined ·‚-TCR/CsA and BMT protocol prolonged median survival time (MST) of VSA to 38 days after i.v. BMT and to 68 days after i.o. BMT (p<0.05). Boost of ·‚ -TCR/CsA (at day 28) prolonged allograft survival up to 78 days after i.v. and up to 90 days after i.o. BMT. In BMT groups chimerism was transient and declined during rejection time. In combined ·‚-TCR/CsA and BMT groups donor-specific chimerism at day 35 revealed 3.9% of RT1a/CD4 and 1.2% of RT1a/CD8 T lympho- cytes after i.v. BMT and 5.4% of RT1a/CD4 and 1.5% of RT1a/CD8 after i.o. bone marrow transplantation. Immunostaining confirmed presence of donor-ori- gin cells (RT1a) in the lymphoid organs of recipients.

Conclusion: Significant extension of VSA survival was achieved under 7-day protocol of ·‚-TCR/CsA augmented with donor BMT. Long-term survival was achieved after boost of ·‚-TCR/CsA therapy given before sign of rejection and was associated with maintenance of donor-specific chimerism. Intraosseous BMT was more effective in chimerism maintenance compared to intravenous BMT.

174 The Differential Effects of Isoflurane and Propofol on Free Tissue Transfer Ischemia-Reperfusion Injury-- A Genomic Analysis Institution where the work was prepared: University of Utah, Salt Lake City, UT, USA Marga F. Massey, MD; Kevin J. Bruen, MD; Dhanesh K. Gupta, MD; University of Utah

Introduction: Ischemia-reperfusion injury is obligated during microvascular free tissue transfers for oncologic reconstruction. If free tissue transfer constructs respond to ischemia-reperfusion injury in a similar manner to myocardium, then general anesthetics should be protective. We report the genomic responses after creation of a free tissue transfer during the administration of isoflurane or propofol. Methods: In a porcine model of vertical rectus abdominus myo-adipo-cutaneous free tissue transfers, equal anesthetic doses of isoflurane (n = 2) or propofol (n = 2) were administered prior to commencing a 3 hour ischemia period followed by a 3 hour reperfusion period. Flap muscle samples were taken at the end of reper- fusion and processed for microarray analysis (Affymetrix GeneChip Porcine Array, Santa Clara, CA). Overall gene expression relative to pre-ischemia samples was calculated using the rank product test. Relative expression was reported as a ratio of expression under isoflurane to that under propofol anesthesia, with ≤0.5 or ?2 considered significant for induction under Propofol or Isoflurane, respectively. Results: Relative gene expression changes and isoflurane/propofol expression ratios are shown in the table. Discussion: During creation of free tissue transfer constructs under isoflurane anesthesia a relative anti-inflammatory state is achieved compared to the pro-inflammatory and pro-thrombotic state observed under propofol anesthesia. Both anesthetics are associated with the induction of various protective heat shock proteins, and propofol induces the hemeoxygenase antioxidant pathway.

Category Gene Title Isoflurane Propofol I/P Ratio Inflammation Interleukin 6 6.3 121.4 .05 Monocyte Chemoattractant Protein-1 6.8 39.2 .17 Alveolar Macrophage-Derived Chemotactic Factor 4.5 25.1 .18 Chemokine Ligand-2 6.9 36.9 .19 Macrophage Inflammatory Protein-1 Beta 109.3 29.6 3.7 Thrombosis Plasminogen Activator Inhibitor-1 13.2 74.2 .18 Plasminogen Activator 4.9 30.5 .16 Tissue Factor 3.6 9.2 .39 Antioxidant Heme oxygenase 4.0 17.2 .23 Protective Heat Shock Protein 70 9.6 35.4 .27 Heat Shock Protein 40 23.1 9.0 2.6 Heat Shock Protein 50 4.0 1.5 2.6

Wound Healing Outcomes Following Pre-operative Radiation Therapy and Limb Surgery for Soft Tissue Sarcoma Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA Pankaj Tiwari, MD1; Gurminder Singh, BA1; Patrick Hsu, MD2; Oluseyi Aliui, BA2; Charles E. Butler, MD3; Howard N. Langstein, MD4; (1)MD Anderson Cancer Center, (2)Baylor College of Medicine, (3)The University of Texas M.D. Anderson Cancer Center, (4)University of Rochester School of Medicine and Purpose: To review the incidence of wound healing complication after pre-operative radiation therapy, extremity sarcoma resection and soft tissue reconstruction. Introduction: Pre-operative radiation therapy in the treatment of soft tissue sarcoma is well accepted to offer an improved survival rate when compared to post-operative radiation. It is also well accepted that pre-operative radiation is associated with higher rates of wound healing complication in the face of local and distant tissue transfer. Although wound healing complications after pre-operative radiation therapy present a concern, the rates of wound healing complication remain unclear as do the ultimate significance of these complications. Methods: We performed a retrospective chart review of 175 patient charts treated at the MD Anderson Cancer Center between 1997 and 2003. Endpoints were sarcoma histologic subtype, method of wound closure, complications after wound closure, number of post-operative wound infections, duration of treatment, incidence of re-operative surgery and overall functional outcome as rated by the patient. Descriptive statistics have been used to evaluate this data. Results: Methods of closure were as follows: primary closure (n=89, 51%), STSG (n=41, 24%), local flap closure (n=59, 34%), pedicled muscle flap (n=35, 20%), free flap (n=23, 13%) free myocutaneous flap (n=8, 5%), free muscle + STSG (n=13, 8%), free fasciocutaneous flap (n=3, 2%), immediate STSG + VAC dressing (n=1, 0.6%) and amputation (n=2, 1%). Complications included infection (n=66, 38%); flap necrosis (n=16, 9%), wound dehiscence (n=16, 9%), skin graft loss (n=6, 3%) and non-healing ulcer (n=4, 2%). Of patients who underwent complications, n=30 (17%) required a second operation. 31 patients (18%) were readmitted to hospital. Irrigation and debridement were performed on n=29 patients (17%). N=12 patients (7%) required local wound care with packing gauze. N=23 patients (13%) required local wound care with moist-to-dry dressing changes. N=9 patients (5%) required STSG as a form of secondary wound coverage after complication. In the immediate post-operative phase n=57 patients (33%) rated their wound healing outcome as excellent. N=84 patients (49%) rated their wound healing out- come as satisfactory. N=3 patients (2%) developed pulmonary metastases post-operatively. N=7 patients (4%) developed post-operative sarcoma recurrence. Conclusions: Our data support prior reports that reconstruction after soft tissue sarcoma resection and pre-operative radiation therapy has a relatively high wound compli- cation rate. Nonetheless, effective wound management yields satisfactory to excellent post-operative outcomes. Pre-operative radiation therapy remains a ben- eficial treatment modality despite high rates of wound healing complication.

175 ASRM Concurrent Scientific Paper Presentations D-1

Pediatric Mandibular Reconstruction with the Vascularized Fibula Flap: A Long-term Evaluation of Outcomes Institution where the work was prepared: MD Anderson Cancer Center, Houston, TX, USA Melissa A. Crosby, MD1; Jack W. Martin1; Geoffrey L. Robb, MD2; David W. Chang1; (1)MD Anderson Cancer Center, (2)The University of Texas M.D. Anderson Cancer Center

Purpose: The use of osseous and osteocutaneous vascularized fibula transfer in the pediatric population has been shown to be a reliable and successful method for mandibular reconstruction after oncologic ablative surgery. Questions concerning long-term growth potential of the reconstructed mandible, donor site mor- bidity, and need for future orthognathic surgery in a skeletally immature patient remain unanswered. We present our experience and outcomes at MD Anderson Cancer Center in mandibular reconstruction using the vascularized fibula flap in the pediatric population.

Methods: A retrospective review of pediatric patients undergoing mandibular reconstruction after ablative oncologic surgery at MD Anderson Cancer Center between 1992- 2005 was performed. Demographic data as well as information concerning flap harvest, complications, functional and aesthetic outcomes were evalu- ated. A series of case examples is presented.

Results: Eleven patients 14 years and younger were found to have undergone mandibular reconstruction with a vascularized fibula flap. Follow-up ranged from 5 months to 10 years. One flap failure occurred due to infection which was salvaged with a second fibula free flap. Recipient site complications including infec- tion, soft tissue abnormalities and hypertrophic scarring were minimal. Donor site complications were more pronounced with revisional surgeries for a cavo- varus deformity and valgus deformity necessary in two patients. Functional outcomes related to occlusion, diet and physical activity were found to be accept- able in all patients. Radiographic evaluation demonstrated adequate bony union in all patients.

Conclusion: Mandibular reconstruction with the vascularized fibula in the pediatric population has been shown to be an efficacious and reliable procedure. In our patient series a high success rate with good functional and aesthetic outcomes was achieved. Follow-up to assess long- term recipient and donor site morbidity once skeletal maturity is reached will be necessary to fully assess outcomes.

Oral function reconstruction by vascular fibular bone flap simultaneous dental implants-12 years experience in Chang Gung Memorial Hospital Institution where the work was prepared: CHANG-GANG MEMORIAL HOSPITAL, TAIPEI, Taiwan Yang-Ming Chang, DDS; F.C. Wei; Chang Gung Memorial Hospital

Objective: This study is aimed to estimate the cumulative survival rate of implants placed in vascularzed flap for oral functional reconstruction

Material & Method: From 1993 to June 2005, 76 patients with various composite jaw bone defects were reconstructed with a fibula osteoseptocutaneous free flap with simulta- neous placement of dental implants. Male 42, female 34, average 50.4 y/o , total 297 implants (280 in fibula bone, 17 in native mandible ). The indications for one stage surgical procedure were: the segmental mandibular defect due to an aggressive benign tumor(52), osteomyelitis(5), and osteoradionecrosis(19). The technique pearls included placement of fibular segment 5 mm higher than the upper native mandible border to overcome problem related to insufficient alveolar ridge height. Use of waxing screws connected with an implant fixture in the fibula – implant construct to confirm a proper interarch relationship and position of the implants, and sural nerve grafting for sensory recovery of the lip sensation in benign tumor cases. In the secondary stage reconstruction, ker- atinized palatal mcuosa graft was performed around dental implants to acquired good oral hygiene environment.

Result: All implants were osseointegated (297/297).The bone loss around the implant was less then 1.5mm in an average 21.6 months oral functional loading follow up. Keratinized mcuosa graft around dental implants provided good oral hygine better than skin graft for patient. The lower lip sensation recovery from post operation 3 month to 18 months duration. Implant supported prosthesis is better than implant tissue support prosthesis

Conclusion: Use of the vertical ridge distraction technique or a double- barrel vascularized fibula bone graft were good methods to correct insufficient alveolar ridge height for segemental mandible reconstruction.

176 Functional Reconstruction of Complex Lip Defect with One Free Composite Anterolateral Thigh Fascia- Cutaneous Flap Institution where the work was prepared: Chang Gung Memorial Hospital, Kaohsiung, Taiwan Yur-Ren Kuo; Seng-Feng Jeng; Jir-Wen Yin, MD; Ching-Hua Hsien; Chang Gung Memorial Hospital in Kaohsiung

Introduction: The anterolateral thigh flaps were used widely in reconstructing skin and mucosa defects after head and neck tumor resection. But when the defects involved oral circumflex, the cosmetic and function results of traditional free flap reconstruction were not satisfied, that secondary commissuroplasty is usually needed. Although some authors reported about reconstructing lower lip with radial forearm-palmaris longus tendon flap. However, the donor site morbidity is its major disadvantage. In this study, we introduce a technique that can provide good oral competence by using vascularized fascia part of anterolateral thigh flaps.

Patients and Methods: Twelve patients with complex lip defect due to composite resection of head and neck surgery during September 2004 to May 2006 was included in this study. The oral sphincter was defined as a complete circumference (200 percent) formed by the upper lip (100 percent) and the lower lip (100 percent) as Jeng et al. had described. The skin and lip defects including upper and lower lips were replaced by a free anterolateral thigh skin flap. The fascia part of flaps were used to provide suspension of flap by anchorage to the remaining orbicularis oris muscle. The tension of fascia suturing was adjusted so that oral competence could be achieved.

Results: Eleven of them were male, and one patient was female. The average age was 52.8 years (ranged from 34 years to 58 years). The average area of defects was96.9cm2, with 8 patients had through and through defect. Lip defect ranged from 50 percent to 120 percent (average 86%). The flap survival was 100 percent, with only one wound infection occurred. All patients had good to excellent oral competence during rest and eating. Six of the 12 patients received thinning procedure of the flap during the operation another 5 of the 12 patients received debulked procedure secondarily. All the donor sites could be closed primarily.

Conclusion: We used the fascia part included in anterolateral thigh flap for providing a vascularized transposition. The fascia was anchored to remaining orbicularis oris muscle so that the resting and dynamic oral competence was good to excellent. This technique provided an altertive of functional reconstruction of oral sphinc- ter in complex lip defect in one stage.

Prefabrication of Trachea for the reconstruction of hemilaryngectomy defects in unilateral laryngeal cancer Institution where the work was prepared: KUL Leuven University Hospitals, Leuven, Belgium Jan Jeroen Vranckx, MD; V. Vanderpoorten, MD, PhD; G Fabre; M Vandevoort; P. Delaere; KUL Leuven University

Background: Every attempt must be made to avoid total laryngectomy in unilateral glottic cancer, because loss of speech and the need for a permanent stoma dramatical- ly alter the quality of a patients' life. For these unilateral cases, we defined a two-staged prefabrication protocol to vascularize a tracheal segment for the recon- struction of the hemilarynx. In a prefabrication procedure, a vascular source is transposed into a non-axial area to provide an alternative blood supply through neovascularization .This prefabrication step allows us to transfer the trachea as a vascularized U-shaped cartilaginous structure. Aim of this procedure is to pre- serve one vocal cord, and thus speech, in cases were current surgical treatment usually consists of total laryngectomy.

Patients and Methods: We treated 70 patients after a hemilaryngectomy with trachea prefabrication. The surgical technique and sequence of these two-stage procedures was sub- stantially modified in this series to allow for more rapid tumour resection during the first stage. The tumor resection is follwed by the trachea prefabrication in the first stage using a radial forearm free flap with a proximal fasciocutaneous and a distal fascia segment. The fasciocutaneous part provides watertight closure of the hemilaryngeal defect, while the fascia flap is wrapped around the required trachea segment for vascular induction. After an oncologic-safe 3-4 months, the prefabricated trachea segment is transplanted as a U-shaped cartilaginous-mucosal flap into the hemilaryngeal defect.

Results: After the first operation the skin paddle of the radial forearm flap succeeded in a restoration of the sphincteric function. The mean time to oral intake for solids was 9.0 days (SD = 2.6 d) and the mean length of hospital stay was 11.2 days (SD = 2.2 d). All patients were able to speak with the tracheal cannula in place. All laryngeal functions were restored after the second operation. The mean time to oral intake for solids was 8.2 days (SD = 5.2 d). The mean time to oral intake for liquids was 16.6 days (SD = 6.3 d), and the mean length of hospital stay was 9.6 days (SD = 2.3 d). The mean time to closure of the tracheostomy and removal of the gastric tube was 27.0 days (SD = 5.8 d).

Conclusion: Prefabrication of a tracheal segment by a vascularized radial forearm free flap allows for tracheal autotransplantation to optimally reconstruct extended hemi- laryngectomy defects. This technique leads to sparing speech in unilateral glottic cancer.

177 Prelamination of Radial Forearm Fascia Flaps for the Treatment of Trachea Re-Stenosis Institution where the work was prepared: KUL Leuven University Hospitals, Leuven, Belgium Wouter Peeters, MD; JJ Vranckx, MD; MD.,PhD Vanderpoorten; G Fabre; M Vandevoort; P. Delaere, MD, PhD; KUL Leuven University

Background: Definitive treatment for trachea re-stenosis after earlier trachea-pull up procedures is challenging. Anastomotic stricture is usually related to excessive tension at the suture line and occurs in approximately 10% of patients undergoing tracheal resection. Reconstruction optimally requires convex shaped, vascularized mucosa-lined tissues. Prelamination allows to transfer the required layers to the trachea by suturing tissue layers on top of a well-defined axial vascular terri- tory. A vascularized free fascia flap prelaminated with buccal mucosa or ear cartilage may augment the airway lumen and may bring a new blood supply into the scarred operation field.

Patients and Methods: Currently 22 patients have been treated with a prelamination protocol for trachea re-stenosis. Five patients were treated in a two-stage procedure with a radi- al forearm fascia flap prelaminated with ear cartilage. Vascular induction (prefabrication) of the thick ear cartilage was required in a first stage before the lam- inated free flap transfer into the tracheal defect. Seventeen patients were treated with a one-stage procedure with bucal mucosa grafts laminated on a fore- arm fascia flap. After microsurgical anastomosis, a tracheal stent is placed for 4-6 weeks, which supports the mucosa-adipofascial flap in loco.

Results: In all patients the stenosis was treated successfully. The mucosal lined reconstruction shows primary healing with a complete take of the oral mucosa on the fas- cial vascular carrier and minimal constriction. A mucosal lining is preferable for airway lining to prevent crusting and desquamation seen when using skin grafts. An exact size-match between the mucosal patch and the defect is paramount. A disadvantage is the absence of supportive tissue. Simultaneous use of a tem- porary silicone stent prevents prolapse of the mucosa-lined fascia in the expanded airway and avoids the use of a two-stage prelamination with ear cartilage.

Conclusions: We use one-or two staged prelamination of mucosa or ear cartilage, sutured on the antebrachial fascia, to reconstruct anterior trachea defects in cases of post- surgical restenosis. Aim is to line the interior trachea with mucosa, while offering structural and vascularized support in a sclerotic area.

Comparison between Anterolateral Thigh Flap and Free Radial Forearm Flap For Hypopharyngeal Defect Reconstruction Institution where the work was prepared: Chang Gung Memorial Hospital, Kaohsiung, Taiwan Johnson C. Yang, MD; Seng-Feng Jeng; Yur-Ren Kuo; Ching-Hua Hsien; Chang Gung Memorial Hospital

Purpose: The free anterolateral thigh (ALT) flap and free radial forearm flap (RFFF) have gained widespread popularity among head and neck reconstructive surgeons for hypopharyngeal reconstruction. Morbidities following hypopharyngeal reconstruction along with donor site morbidities when using these two flaps will be evaluated in this retrospective study.

Patients and Methods: From August 1999 to May 2006, a total of sixty-five patients have received forty-two radial forearm flap and 24 free anterolateral thigh flaps for the recon- struction of hypopharyngeal defects after tumor ablation. All the reconstruction were performed by the same senior author. All patients were males with age ranged from 36 to 76 years, averaging 54.4 years old. Fifty-one skin tubing and fifteen patches were designed for the defects. The pharyngoesophageal defects ranged from 6 to 20 cm in length, averaging 11.0 cm. The outcomes were compared.

Results: All free flap transfers were successful in the RFFF group except one, which was replaced with a free ALT flap. All flap transfer were successful in the ALT group. Among the RFFF group, venous thrombosis occurred in one flap which was salvaged successfully. Wound infection rate were 7/24 (29.1%) and 4/42 (9.5%) in the ALTand RFFF group, respectively. Only one patient in the ALT group required surgical intervention. Temporary fistula formation was 5/24 (20.8%) and 13/42 (31%) in the ALT and RFFF, respectively. Three out of five patients (60%) and nine out of thirteen patients (69.2%) who developed fistula required surgical intervention for fistula closure in the ALT and RFFF group, respectively. Postoperative esophagograms had done in 8 patients/24 in ALT group, no narrowing was found. However, 25 patients/42 patients in RFFF group, 6 patients had short segmental narrowing, 2 had total occlusion. Primary donor site closure was achieved in all ALT donor sites with no sequlae. Split thickness skin graft was used for all radial forearm donor site coverage with two partial skin graft loss was noted.

Conclusion: ALT flap is a versatile flap for reconstruction of hypopharyngeal cancer. When compared with traditional RFFF. It had less donor site morbidity and better func- tional results.

178 Extended Left Colon Interposition for Esophageal Reconstruction Using Distal End Supercharge Procedure Institution where the work was prepared: Chang Gung Memorial Hospital- Kaohsiung Medical Center, Kaohsiung, Taiwan Yur-Ren Kuo, MD, PhD, FACS; Nai-Siong Kueh; Hung-I Lu; Chih-Yen Chien; Chang Gung Memorial Hospital- Kaohsiung Medical Center, Chang Gung University

Background: Esophageal reconstruction after esophagectomy is a serious problem for patients in whom the gastric pull-up is not available. For these patients colon inter- position is the best alternative procedure. However, the most serious complication is high incidence of distal ischemia necrosis of colon induced leakage of the esophagocolostomy, even resulting in mortality. Herein, we presented a supercharge blood perfusion procedure to distal colon interposition without any com- plication. Materials and

Methods: From past three years, we had four patients who had undergone colon interposition for esophagus reconstruction. All patients had hypopharyngeal cancer with cervical esophagus invasion. Two patients were male and two were females. Their age ranged from 45 to 63 year-old with a mean of 52 year-old. After can- cer ablation, the defect from tongue base to cervical esophagus was found. The causes of colon interposition were gastric pull-up was unavailable due to insufficient length. The extended left colon from sigmoid to mid-transverse colon supplied from left main colic artery and middle colic artery arcade branch to be divided at the hepatic flexor was performed. When this was done, insufficiency supplied transverse colon was found. The vessels supercharge technique from distal end of middle colic artery branch to superior thyroid artery (two cases), facial artery (one case), or transverse cervical artery (one case) were per- formed under microvascular anastomosis.

Results: All the patients received supercharged technique revealed good blood circulation and peristalsis of colon interposition graft peri-operatively. The increased colonic length ultimately resulted in reduced tension on the left colic pedicle. There was no leakage or colon graft necrosis in the hypopharygocolostomy junction. The bar- ium swallowing study revealed a wide patent anastomosis postoperatively. All patients tolerated regular diet smoothly after discharged home.

Conclusion: Supercharge procedure during extended colon interposition is a useful technique to prevent any serious complications by providing additional blood supply to colon graft.

Swallowing Outcomes after Microvascular Head and Neck Reconstruction: A Prospective Review of 191 Cases Institution where the work was prepared: Cleveland Clinic Foundation, Cleveland, OH, USA Samir Khariwala1; Prashant Vivek1; Ramon Esclamado, MD2; Benjamin Wood1; Robert Lorenz1; Marshall Strome1; Daniel Alam, MD1; (1)Cleveland Clinic Foundation, (2)Duke University Medical Center

The use of microvascular free tissue flaps tailored specifically to the ablative surgical defects has allowed precise anatomical reconstructions to be performed and in turn improved patient outcomes. We report here the postoperative swallowing outcomes of patients undergoing microvascular reconstructions for a range of head and neck defects at the Cleveland Clinic. The study includes 191 consecutive reconstructions for varied defects. All patients were reconstructed with 4 specific microvascular flaps based on their surgical defect and post operative swallowing outcomes are evaluated and recorded on a prospectively main- tained database. Pre and post operative swallowing was graded on an ordinal scale. Data was simultaneously collected on the precise anatomical ablative defect in each patient subdividing the head and neck into 16 sub sites. A multivariable analysis was performed based on this database analyzing co morbid factors, type of flap used, and sub site of defect. The findings are summarized as follows. There were no flap failures. 78.5% of patients were able to swallow and maintain an exclusively oral diet postoperatively. Only 16.8% were NPO and gtube dependent for feeding. The factors that predicted an inability to swallow include tongue resection, pre-operative radiation therapy, and hypopharyngeal defects. In contrast, floor of mouth, mandibular, and pharyngeal defects regard- less of size had excellent long term swallowing outcomes. Most patients with these defects were able to tolerate at least a soft solid diet. In summary, we report excellent postoperative swallowing outcomes from microvascular reconstructions at our institution which compare favorably over outcomes with pedi- cled flaps and historical controls. The type of flap used and the size of defect had minimal effects on swallowing outcomes. The most difficult sub sites to reconstruct were tongue defects which strongly correlated with poor swallowing outcomes. The other factor that strongly impacted outcomes was preopera- tive radiation treatment. We believe these results highlight the utility of free flaps in recreating the precise anatomy required to maintain intact swallowing. This data will hopefully support numerous previous studies which have established the use of microvascular reconstruction as standard of care for ablative sur- gical defects in the head and neck.

Comparison Between Jejunum and Ileocolon Flaps in Terms of the Risk of Food Aspiration After Voice Reconstruction Institution where the work was prepared: E-Da Hospital, Kaohsiung, Taiwan Hung-Chi Chen, MD, FACS1; Yueh-Bih Tang, MD, PhD2; Samir Mardini, MD1; Christopher Salgado1; (1)E-da/I-I Shou University Hospital, (2)National Taiwan University Hospital

BACKGROUND: In transferring intestine for reconstruction of cervical esophagus and voice tube, the major concern is food reflux and aspiration. Two common methods were compared in such reconstruction, namely jejunum and ileocolon flaps.

METHODS: From 1998 to 2006 there were 106 patients who underwent simultaneous reconstruction of cervical esophagus and voice tube after total pharyngolaryngectomy. Among them 32 were jejunal flap and 74 were ileocolon flap. The condition of dietary intake, incidence of food reflux and pneumonia attacks were recorded after surgery.

RESULTS: In the group of jejunal flap, 17/32 (53 %) still had food reflux into the voice tube and caused choking, especilly when liquid diet was taken. However, none of them really suffer from aspiration pneumonia because their trachea still preserved sensation and were able to cough out the aspirated material. In the group of ileocolon, only 2/74 had occasional aspiration due to loosening of the plicated ileocecal valve. They underwent revion for the ileocecal valve and had no more aspiration. None of them developed aspiration pneumonia, either.

CONCLUSION: The flow of content inside the intestine is actually like a tide wave. Only ileocecal valve is effective to prevent food reflux. Aspiration does not necessarily cause pneumonia, but it intimidates the patients in oral intake of food, as well as voice function. Therefore ileocolon flap is recommended because it is more effec- tive to prevent reflux of GI content when a voice tube is reconstructed.

179 ASRM Concurrent Scientific Paper Presentations D-2

Effect of Cooling on Vascular Alpha-Adrenergic Receptor-Mediated Responses in Primate Digital Arteries Institution where the work was prepared: Wake Forest University School of Medicine, Winston-Salem, NC, USA Delrae M. Eckman, PhD; Mamta Fuloria, MD; Michael F. Callahan, PhD; Suzanne E. Watt; Janice D. Wagner, DVM, PhD; Thomas L. Smith, PhD; L. Andrew Koman, MD; Wake Forest University School of Medicine

Background: Cutaneous vasoconstriction in response to a cold stimulus is a protective physiologic thermoregulatory mechanism for maintaining thermal homeostasis. This phenomenon is thought to be mediated in small arteries and arterioles, at least in part, via augmented ?2-adrenergic receptor (?2-AR) activity. The majority of studies evaluating mechanisms underlying cold-induced vasoconstriction in isolated arterial preparations have been performed in vessels other than digital arteries. Thus, these studies may not accurately reflect the physiologic mechanism(s) responsible for cold-induced constriction in digital arteries. Objective: Few studies have specifically assessed isolated primate digital artery vasoconstriction with cooling. The intent of this study was to determine: (1) the response of primate (human and non-human) digital arteries to cooling, and (2) the contribution of ?-AR activation to cooling-induced vasoconstriction in primate (human and non-human) digital arteries. Our findings in primate digital arteries led us to perform a similar series of experiments in murine distal tail arteries so as to demonstrate our ability to replicate the observations and address the results of current experiments in context with those made by other investigators study- ing this vascular bed.

Methods: After assessing vascular smooth muscle and endothelial integrity, we determined the effect of cooling from 37°C to 23°C on (1) K+-induced constrictions, and (2) ?1 (phenylephrine), ?1/?2 (norepinephrine), and ?2 (UK-14,304) AR activation on vascular tone in isolated, cannulated primate digital and murine tail arteries.

Results: Cooling of primate (human and non-human) digital and murine tail arteries to 23°C had no effect on resting arterial tone. Vascular smooth muscle depolariza- tion-induced constrictions to 50 mM KCl were significantly attenuated at 23°C as compared to 37°C in primate digital arteries (p<0.05). Furthermore, attenuation of both ?1- and ?2-adrenergic agonist-induced constrictions with cooling in primate digital arteries was observed (p<0.05). In contrast, the constriction to 50 mM KCl in murine tail arteries was comparable at 37°C and 23°C. Additionally, we observed no difference in the constriction of murine tail arteries to ?1-AR stimula- tion but observed enhanced constriction to UK-14,304, an ?2-AR agonist, with cooling from 37°C to 23°C.

Conclusion: These data demonstrate that, in contrast to murine distal tail arteries/human forearm and gluteal vessels, human and non-human primate digital arteries demon- strate attenuated constrictions to elevated [K+]o and ?-AR stimulation when cooled to 23°C. These data also suggest that previously published reports demonstrat- ing augmented ?2-AR signaling with cooling (37°C to 28°C) may by species and/or vascular bed dependent.

Ethyl Nitrite in the Management of Microsurgical Vasospasm in a Rat Model Institution where the work was prepared: Duke University Medical Center, Durham, NC, USA Alessio Baccarani, MD; Koji Yasui; Kevin C. Olbrich; Ahmed El-Sabbagh; Stephen Kovach; Keith E. Follmar; Detlev Erdmann; L. Scott Levin; Jonathan S. Stamler; Bruce Klitzman; Michael R. Zenn; Duke University

Background: Vasospasm leading to thrombosis is a major cause of free flap failure. Flap blood flow may improve by application of vasodilating agents to the pedicle. Historically, lidocaine or papaverine have been topically applied intraoperatively to resolve or prevent vasoconstriction, however their use has not always been effective at restoring impaired blood flow. Nitric oxide is a potent vasodilating agent. The purpose of this study was to evaluate the effect of O-ethyl-nitrite (ENO) on flap blood flow and pedicle vessels diameter in a rat model.

Methods: Male CD rats (Charles River Laboratories, Raleigh, NC; n=26) had abdominal flaps (3 x 3 cm) raised unilaterally based on the inferior epigastric artery and vein. Pedicle vasoconstriction was induced by topical endothelin-1 (ET-1; 3 x 10-5 M) and by pedicle clamping for 15 minutes. After 15 minutes, either saline (con- trol, n=6 rats), 20% lidocaine (n=7 rats), 10-4 M ENO (n=8 rats), or a combination of both drugs (n=5 rats) was applied topically in a single application. Over the subsequent 180 min, flap blood flow was measured with a laser Doppler flowmeter and the diameter of pedicle vessels was measured manually every 15 minutes. Data were statistically analyzed using a Mann Whitney U-test.

Results: At 2 hours post operatively, the arterial diameter was significantly (p<0.05) dilated by treatment with both ENO, lidocaine, and lidocaine + EN0. None of these treatments had a statistically signficant effect on blood flow or venous diameter. Twenty-four hours following surgery, both ENO- and LID-treated groups had larger arteries than the control group (p<0.05). The ENO treated animals also had signficantly (p<0.05) elevated blood flow compared to control animals, but LID-treated animals did not demonstrate any improved flow at 24 hours. None of the treatments had any significant impact on venous diameter at 24 hours.

Conclusions: ENO may become clinically useful in microvascular surgerical procedures, perhaps in combination with lidocaine.

180 Vascular Injuries in Very Small Children: An Algorithm for Diagnosis and Treatment Institution where the work was prepared: Texas Children Hospital, Houston, TX, USA Jamal Bullocks, MD1; Jeffrey D. Friedman, MD2; Michael Klebuc, MD2; (1)Baylor College of Medicine, (2)The Methodist Hospital

Introduction: Vascular injuries in neonates and small children are a relatively uncommon complication of invasive catheterization procedures. From a clinical perspective, these injuries present in the form of an ischemic limb that is typically swollen, mottled and cold to the touch. In most cases it is difficult to identify the exact nature of the underlying injury and differentiate acute thrombosis from severe arterial spasm and/or compartment hypertension. At our institution, we have developed an algorithmic approach to the diagnosis of these injuries so that appropriate treatment measures can be instituted.

Materials and Methods: A retrospective review was performed on 30 patients presenting with an acutely ischemic extremity. Physical examination, color Doppler ultrasound, and close monitoring was carried out in each case. Patients were treated with the following algorithm:

Results: In all cases associated with a normal Doppler examination there were no instances of significant soft tissue loss despite numerous interventions for soft tissue release. Those patients with a demonstrated occlusion of a major peripheral vessel, operative intervention provided for limb salvage in all patients despite one postoperative death and an additional patient requiring an above knee amputation 1 year post limb salvage due to a severe limb growth disturbance.

Conclusion: The combined use of serial clinical examinations, color Doppler ultrasound, and operative intervention has proven successful in maximizing limb salvage in children with devastating vascular injuries. We now employ this algorithm of treatment as our standard methodology when faced with severely ischemic limbs of uncertain etiology.

A New Rat Model for Brachial Plexus Birth Injury Associated Shoulder Deformity Institution where the work was prepared: Wake Forest University Health Sciences, Winston-Salem, NC, USA Zhongyu Li, MD, PhD1; Jianjun Ma1; Cathy S. Carlson, PhD2; Thomas L. Smith, PhD1; L. Andrew Koman, MD1; (1)Wake Forest University Health Sciences, (2)College of , University of Minnesota

Aim: The aim of this study was to establish an animal model to study brachial plexus birth palsy (BPBP) related shoulder deformity. BPBP is not uncommon, and the result is often devastating. Clinical studies have shown that shoulder contracture occurs in at least one-third of the children who sustain BPBP with delayed recovery and in at least two-thirds of children with incomplete recovery.

Materials and Methods: A right side C5, C6 axotomy was performed under the microscope in 3 day old Sprague Dawley rats (n=4, male and female). The contralateral side served as a con- trol. The development of shoulder deformity and range of motion of shoulder were followed longitudinally for 4 months. Animals were euthanized 4 months after surgery. Both shoulders were harvested, decalcified in formic acid, and transected in the axial plane for glenohumeral version measurement and joint histology.

Results: All animals developed right shoulder internal rotation deformities within 4 weeks after the C5,6 axotomy. The average shoulder external rotation was 63.8% of the control side (96±9° vs. 156±9°; p<0.01, Figure 1). Glenoid version was changed from a mean of 9.75° of retroversion (left side) to a mean of 8.75° of anteversion (P<0.001). Two shoulders (50%) were subluxed clinically with a pseudoglenoid formation on the radiographic image (Figure 2). Histological study demonstrated glenoid cartilage thickening (Figure 3).

Conclusion: This rat model clearly demonstrated typical shoulder deformities after brachial plexus birth injury (Erb's palsy). Use of this model will provide a method for studying the mechanism and natural history of BPBP-related shoulder deformity and for the development of new approaches in the prevention and treatment of the secondary shoulder deformity after BPBP.

181 Anatomy and Hystology of the Latissimus Dorsi Subunits for Facial Reanimation Institution where the work was prepared: Souza Aguiar City Hospital and Federal University of São Paulo, Rio de Janeiro and São Paulo, Brazil André Salo Buslik Hazan, MD1; Fábio Xerfan Nahas, PhD, MD2; Marcus Vinícius Jardini Barbosa, PhD, MD2; Eugênio Piñeda, PhD, MD3; Lydia Masako Ferreira, PhD, MD2; (1)Souza Aguiar City Hospital of Rio de janeiro and Federal University of São Paulo, (2)Federal University of São Paulo, (3)Souza Aguiar City Hospital

BACKGROUND: The use of muscular flaps for the correction of defects after mimetic muscles damage has been described. However, these flaps showed restrictions because of the large volume of muscle transferred and the vector in a single direction. Recently, perforator flaps has been widely used but its limitation is offer only cuta- neous cover. The goal of this type of reconstruction is to restore both muscular and cutaneous cover with tissues that presents similar size and thickness of the damage multiple mimetic muscles of the face with different force vectors. The purpose of this study is to present the anatomy and histology of the latis- simus dorsi subunits for facial transplantation and to present a case report with this alternative reconstruction technique.

METHODS: Ten fresh adult cadavers were dissected. The latissimus dorsi muscle was dissected and the perforators vessels are identified. The vessel that supplies the overlying skin is individualized. Dissection proceeds into the muscle, sectioning the epimysium and the perimysium, individualizing the lateral segmental bundle or the infe- rior one. Then, the vascular and nervous subsegmental bundles penetrating the corresponding muscular groups are observed. The neurovascular subsegmental bun- dles and the muscular subunits are isolated by dissection. Each subunit was isolated and was histologically evaluated. A histological search for an artery, a vein and a nerve was performed 3 mm before and right at the penetration of the pedicle within the muscle. The external diameters of these structures were measured.

RESULTS: Subunits of independent muscles were created. They are supplied by a subsegmental vessels pedicle connected to a lateral or inferior segmental vessel, which is a branch of the thoracodorsal vessel. Histological study showed that ninety eight percent of the subunits presented at least one artery, one vein and one nerve.

CONCLUSION: This study supports the use of subunits of latissimus dorsi flap as a substitute of mimic facial muscles.

The Free Partial Superior Latissimus (PSL) Muscle Flap: Preservation of Donor Site Form and Function Institution where the work was prepared: The Buncke Clinic, San Francisco, CA, USA Karen M. Horton, MD, MSc, FRCSC; Rudolf F. Buntic, MD; Darrell Brooks; Charles K. Lee; The Buncke Clinic

PURPOSE: The latissimus dorsi flap is widely applied, reliable and versatile for microvascular reconstruction. Harvest of the entire muscle results in sacrifice of form, creates a large donor space, and may create functional loss. Use of the superior portion only decreases donor site morbidity and provides a flap of variable size. We describe the partial superior latissimus (PSL) muscle flap, its harvest technique, and application as a microvascular transplant for complex defects in thirteen patients.

METHODS: The superior portion of the latissimus dorsi is isolated on the transverse branch of the thoracodorsal artery though a transverse incision parallel to the upper muscle border. The pedicle is followed proximally as needed for sufficient length. For functional PSL muscle transfer, the transverse branch of the thoracodor- sal nerve is dissected intraneurally, leaving the branch to the lateral latissimus intact.

RESULTS: Thirteen patients have undergone PSL flap procedures: 11 were used for extremity salvage or complex wounds, 2 were transplanted for facial reanimation and one sen- sory innervated flap was used to achieve a sensate heel. Flap dimensions ranged from 10 x 5 cm to 24 x 12 cm. All flaps survived; one hematoma occurred in a patient on perioperative heparin. A symmetrical lateral thoracic silhouette was maintained and the remaining latissimus muscle functioned postoperatively in all patients.

DISCUSSION: Harvest of the superior portion of the latissimus muscle on the transverse branch (TB) of the thoracodorsal vessels (TDA) preserves the entire lateral and infe- rior elements of the muscle via the descending branch (DB), together with its nerve supply. This preserves the lateral thoracic form and decreases potential functional muscle loss. Similar to the partial medial rectus flap, a reliable muscle flap of variable size can be designed while preserving donor site form and function. “Muscle-sparing” latissimus flaps have been described; however, lateral muscle dissection or complete muscle harvest were used. Innervation of the PSL flap and neurrorhaphy to a recipient motor nerve enables functional muscle transplantation.

CONCLUSIONS: The PSL flap has the following advantages: (1) variable flap size, (2) large caliber vessels, (3) a potentially long vascular pedicle, (4) preservation of the major- ity of the latissimus muscle in situ, (5) maintenance of the dorsal thoracic silhouette, (6) potential for neurotization and sensory/functional muscle reconstruc- tion and (7) use as a myocutaneous flap by including the overlying skin territory. Thirteen cases have been successfully completed for a variety of anatomic defects and reconstructive purposes.

182 Cluster Analysis and Vascular Anatomy of the Radial Forearm Flap Cutaneous Perforators: A Cadaver Study Institution where the work was prepared: Christine M Kleinert Institute, Louisville, KY, USA Mirsad Mujadzic, MD; Christine M. Kleinert Institute for Hand and Microsurgery; Ruben N. Gonzalez, MD; Christine M. Kleinert Institute, Jewish Hospital; A. Scott LaJoie, PhD, MSPH; University of Louisville; Dan Hatef, MD; UT Southwestern; Michel Saint-Cyr, MD; UT Southwestern Medical Center at Dallas Purpose: To define the location, size, and vascular cutaneous territory of the forearm cutaneous perforators originating from the radial artery. Methods: 26 fresh human cadaveric forearm dissections were performed. The brachial artery was injected with 20 cc of Microfil Red 24 hours prior to dissection. All cuta- neous perforators originating from the radial artery were analyzed for total number; ulnar versus radial orientation; location relative to both the radial styloid distally and the lateral epicondyle proximally; external diameter; and clustering. A cluster analysis was performed to determine the overall distribution of all cutaneous perforators originating from the radial artery. The vascular cutaneous territory of a distally-based pedicled perforator flap was determined using methylene blue injection and standard lead oxide radiography. Results: A total of 639 perforators (399 perforators < 0.5 mm vs. 240 perforators ? 0.5 mm), were dissected in 26 forearms. Of the 639 radial artery perforators dis- sected, 328 perforators were radialy distributed, and 311 were ulnarly distributed. Of the radialy directed perforators, 128 were clinically relevant (? 0.5mm external diameter) versus 200 perforators with an external diameter of < 0.5mm. Of the ulnarly directed perforators, 112 were clinically relevant (? 0.5mm exter- nal diameter) versus 198 perforators with an external diameter of < 0.5mm. Cluster 0.5 mm in?analysis revealed three main clusters of perforators diameter located proximal to the radial styloid at a relative distance of 12%, 34% and 63 % from the radial styloid and lateral epicondyle interval. For clinically relevant perforators ? 0.5 mm in diameter, 2 main clusters were identified at a distance of 18% and 62% proximal to the radial styloid along the radial styloid and lat- eral epicondyle interval. Chi square analysis revealed no statistical difference in either radial or ulnar distribution of the cutaneous perforators from the radial artery (P = 0.451). In 100% of all cases, 2 perforators were found within 2 cm proximal to the styloid. Injection of methylene into the perforators found with- in 2 cm proximal to the styloid revealed a flap cutaneous territory ranging from 104 cm2 to 333 cm2. Conclusions: It is demonstrated in this study that there are two main clusters of clinically significant perforators. Increased knowledge related to size, location, and cuta- neous territory of the radial artery perforators can eventually lead to an expanded clinical use of the radial artery forearm flap based on cutaneous perforators alone without sacrifice of the radial artery.

New Method for Real-Time Muscle Flap Viability Monitoring Institution where the work was prepared: Chaim Sheba Medical Center, Tel Aviv, Israel Benjamin Meilik, MD; University of Toronto; Batia Yafe, MD; Chaim Sheba Medical Center at Tel Hashomer; Arie Orenstain, MD, Profesor; Chaim Sheba Medicl Center at Tel Hashomer Background: Soft tissue viability is usually assessed clinically, observing tissue color, capillary refill, and post needle-puncture bleeding. Other methods for monitoring flap viability include Doppler Ultrasonography, Laser Doppler flowmetry, and Pulse Oxymetry. No monitoring technique fulfills all the criteria of an ideal one: reli- ability, accuracy, noninvasiveness, continuously, reproducibility, low cost, and easy interpretability. In reflection spectrophotometry, the spectrum of the light reflected back from each point on the surface of the monitored tissue is analyzed. It is then compared with the known spectrum of oxy/deoxy hemoglobin and oxygenation status of the tissue is calculated and displayed as oxygen saturation maps (OSM) in which false colors represents the level of oxygenation of the tissue. In the first part of this study (presented elsewhere), it was demonstrated that tissue OSM, produced using reflection spectrophotometry, are reliable and consistent in predicting the viability of a random skin flap in a rat model. Goal: This part of the study was designed to determine whether viability of a muscle flap can be predicted, using tissue OSM produced using reflection spectrophotometry, in a rat model. Material and Methods: In a group of 10 Charles-River male rats, mean weight- 348 gm (34gm Std), using a microsurgical microscope, Rectus Abdominis muscle was dissected free from all the surrounding tissue and left connected only to it's major and minor vascular pedicles: the superior and inferior epigastric arteries respectively. After taking baseline monitoring OSM, the superior epigastric artery was divided (blood supply to the muscle is based now only on it's minor vascular pedicle), and 20 minutes later anoth- er monitoring OSM was performed. The muscle was then wrapped with a nylon sheet and the abdominal skin was closed on top of it. At postoperative day 3 (POD3), a plain digital picture of the flap was taken to demonstrate the location of necrosis demarcation line on the flap. Reflection spectrophotometry tissues OSM were pro- duced using a prototype device of a spectral imaging system. Feasibility test of the device for this rat model was done using Pulse Oxymetry. Results: Transposing necrosis demarcation line (on POD3) to the 20 minutes monitoring OSM, revealed minimal saturation value sufficient for muscle viability. Mean saturation was 51.9 % (4.4 Std). Reliability analysis test demonstrated an alpha coefficient of 0.78 (a relative high reliability score). Conclusions: Prediction of muscle viability in this rat model can be done reliably and consistently using OSM produced by reflection spectrophotometry

Treatment of Symptomatic Diabetic Peripheral Neuropathy by Surgical Decompression of Three Peripheral Nerves Institution where the work was prepared: Peking Union Medical College, Beijing, China Yong Yao, MD; R-Z. Wang, MD; Peking Union Medical College For more than a decade, successful nerve decompression in the lower extremity of diabetics in the United States has been reported. In the United States the incidence of diabetes is reported as 6% in the Caucasian, 10% in the African American and 15% in the Hispanic population. In China, the incidence of dia- betes is approaching this 15% level, and it is anticipated that progressive problems with neuropathy will be a large national health burden. Therefore, it is important to learn if the approach described by Dellon for the "triple decompression procedure" in the lower limbs of diabetics can be applied to the popula- tion of patients with diabetes in China. In 2004, one of us (Y.Y.) studied with Dr Dellon and beginning in January of 2005 applied neurolysis of the peroneal nerve at the knee and dorsum of foot, and neurolysis of branches of the tibial nerve in the four medial ankle tunnels to patients with diabetes in good glycemic control, who had a positive Tinel sign over the tarsal tunnel. Objectives To discuss the surgical outcome in diabetic peripheral neuropathy (DPN)patients treat- ed by decompression of three peripheral nerves. Methods 90 patients accepted decompression of common peroneal nerve, deep peroneal nerve and posterior tibial nerve. The clinical date have been followed up 6-20 months. Two patients had a previous ulceration and one patient had a previous amputation of a toe. Results; For pain, using Visual Analog Scale, 94% of patients have had relief of pain. For sensibility, using two-point discrimination, 90% of patients have had improvement in sensibility. There have been no new ulcers or amputations. It is concluded that the diabetic patients in China have superimposed nerve compressions, and their symptoms can be relieved and new ulcers and amputations can be prevented by doing the Triple Nerve Decompression procedure.

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