AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

PROGRAM 

B O O K 

AAHS 

January 10-13, 2007 

ASPN 

January 13-14, 2007 

ASRM 

January 13-16, 2007 

2007 ANNUAL SCIENTIFIC MEETINGS 

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The Westin Rio Mar Beach Resort - Rio Grande, Puerto Rico

The Westin Rio Mar 

Beach Resort 

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TABLE OF CONTENTS 

AAHS Board of Directors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

AAHS Committees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 

AAHS Historical Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

Hand Surgery 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 Hand Surgery 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 

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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 


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 

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AAHS HISTORICAL INFORMATION 

AAHS PAST PRESIDENTS 

J. Joseph Danyo, MD 1970-1972 

Henry Burns, MD 1972-1973 

Ray A. Elliott, Jr., MD 1973-1974 

James Borden, MD 1974-1975 

Kim K. Lie, MD 1975-1976 

Frank L. Thorne, MD 1976-1977 

Lawrence R. Werschky, MD 1977-1978 

Robert T. Love, MD 1978-1979 

Arnis Freiberg, MD 1979-1980 

Thomas J. Krizek, MD 1980-1981 

George L. Lucas, MD 1981-1982 

Garry S. Brody, MD 1982-1983 

James G. Hoehn, MD 1983-1984 

Peter C. Linton, MD 1984-1985 

Wallace H.J. Chang, MD 1985-1986 

Austin D. Potenza, MD 1986-1987 

Lee E. Edstrom, MD 1987-1988 

C. Lin Puckett, MD 1988-1989 

Robert J. Demuth, MD 1989-1990 

Wyndell H. Merritt, MD 1990-1991 

Frederick R. Heckler, MD 1991-1992 

Robert D. Beckenbaugh, MD 1992-1993 

David J. Smith, Jr., MD 1993-1995 

James W. May, Jr., MD 1995-1996 

Robert H. Brumfield, Jr., MD 1996-1997 

Robert C. Russell, MD 1997-1998 

Peter C.amadio, MD 1998-1999 

William M. Swartz, MD 1999-2000 

William Blair, MD 2000-2001 

Robert Buchanan, MD 2001-2002 

Alan Freeland, MD 2002-2003 

Allen Van Beek, MD 2003-2004 

Richard Berger, MD 2004-2005 

Susan Mackinnon, MD 2005-2006 

PRESIDENTIAL INVITED LECTURERS 

Harold E. Kleinert, MD 1989 

Arthur C. Rettig, MD 1990 

Paul W. Brand, MD 1991 

Ronald L. Linschied, MD 1993 

Guy Foucher, MD 1995 

Michael R. Harrison, MD 1996 

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 

KEYNOTE SPEAKERS 

William L. White, MD 1978 

John W. Madden, MD 1979 

Harold E. Kleinert, MD 1980 

J. William Littler, MD 1981 

Clifford C. Snyder, MD 1982 

Robert A. Chase, MD 1983 

Richard J. Smith, MD 1984 

James M. Hunter, MD 1985 

Bernard McC. O’Brien, MD 1986 

Erle E. Peacock, Jr., MD 1988 

Michael Jabelay, MD 1989 

Robert M. McFarlane, MD 1990 

James H. Dobyns, MD 1991 

Adrian E. Flatt, MD 1992 

John B. Carlson, PhD 1993 

Pat Clyne 1995 

David M. Evans, FRCS 1996 

Eugene Nelson, MD 1997 

Fritz Klein 1998 

Janet L.Babb 1999 

Frank E. Jones, MD 2000 

Joseph Buckwalter, MD 2001 

Linda Cendales, MD 2002 

Arnold-Peter Weiss, MD 2003 

Terry L. Whipple, MD, FACS 2005 

Jeff Lichtman, MD, PhD 2006 

CLINICIAN/TEACHER OF THE YEAR 

Forst Brown, MD 1995 

Robert Beckenbaugh, MD 1996 

James Hoehn, MD 1997 

Alan Freeland, MD 1998 

Wyndell Merritt, MD 1999 

Peteramadio, MD 2000 

Anthony DeSantolo, MD 2002 

Michael Jabaley, MD 2002 

Maureen Hardy 2002 

Sterling Mutz, MD 2002

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) 

Joseph Danyo, MD 

Alan Freeland, MD 

Robert Schenck, MD 

EMERALD 

(Cumulative giving up to $10,000) 



Miguel Saldana, MD 

James Schlenker, MD 

RUBY 


Anthony Brown, MD 

Ali Seif, MD 

Allen Van Beek, MD 

SAPPHIRE 


Stephan Ariyan, MD 

Mark Baratz, MD 

Rocco Barbieri, MD 

John Bax, MD 

William Benson, MD 

Beth Ann Bergman, MD 

Phillip Blevins, MD 

Forst Brown, MD 

Richard Brown, MD 

William Brown, MD 

Robert Buchanan, MD 

A. Lawrence Cervino, MD 

David T.W. Chiu, MD 

Jerry Chow, MD 

James Clayton, MD 

Mark Cohen, MD 

David Conner, MD 

James Cullington, MD 

Donald Ditmars, MD 

Richard Fox, MD 

Felix Freshwater, MD 

Robert Gardere, MD 

William Geissler, MD 

Neil Green, MD 

Robert Harris, MD 

Fred Heckler, MD 

David Hildreth, MD 

James Hoehn, MD 

Peter Hui, MD 

Richard Idler, MD 

Ted Jackson, MD 

Ronald Joseph, MD 

Scott Kozin, MD 

George Landis, MD 

John Lang, MD 

W.P. Andrew Lee, MD 

William Leighton, MD 

JoAnn Levitan, MD 

Kim Lie, MD 

Ho Min Lim, MD 

Shelia Lindley, MD 

Robert Love, MD 

George Lucas, MD 


James May, Jr., MD 

W. R. McArthur, MD 

Vaughn Meyer, MD 

Susan Michlovitz, PT, PhD 

Ather Mirza, MD 

Hiram Morgan, MD 

Nash Naam, MD 

Daniel Nagle, MD 

A Lee Osterman, MD 

Edward Palmer, MD 

Swainathan Rajan, MD 

Norman Rappaport, MD 

Jaiyoung Ryu, MD 

Amorn Salyapongse, MD 

Somprasong Songcharoen, MD 

William Swartz, MD 


Eric Wegener, MD 

Michael White, MD 

Eric Wyble, MD 

TOPAZ 

(Cumulative giving of $1,000) 

Alejandro Badia, MD 

Kyle Bickel, MD 

Randy Bindra, MD 

Robert Costarella, MD 

Richard Demuth, MD 

Michael Kalisman, MD 

Albert Weiss, MD 

HONOR ROLL 

(Cumulative giving less than $1,000) 

Dorit Aaron, MA, OTR,CHT 

Govind Acharya, MD 

Brian Adams, MD 

Lisa Adams, CVE, CHT 

Medhi Adham, MD 

Galaa Agban, MD 

Joseph Agris, MD 

John Alipit, MD 

Bernard Alpert, MD 

Peteramadio, MD 

Chittur Ananthakrishnan, MD 

Dimitri Anastakis, MD 

William Anderson, MD 

Cary Andras, MD 

Michael Angel, MD 

4 

Alexander Angelides, MD 

Mallory Anthony, RPT 

John Anton, MD 

Dori Ann Appleman, OTR,CHT 

Thomas Arganese, MD 

Enrique Armenta, MD 

William Armiger, MF 

Laurence Arnold, MD 

Michael Aron, MD 

Kenneth Arthur, MD 

Tyrone Artz, MD 

Stanley Askin, MD 

Edward Athanasian, MD 

John Attwood, MD 

John Aversa, MD 

Samir Azer, MD 

Medhi Balakhani, MD 

Joyce Baldwin, OTR/L, CHT 

George Balfour, MD 

Brent Bamberger. MD 

Adel Barakat, MD 

John Barham, MD 

David Barker, MD 

Bruce Barton, MD 

M. L. Barton, MD 

Lynn Bassini, OTR, CHT 

Basilio Bautista, MD 

Carlos Bazan, MD 

Michael Beatty, MD 

Robert Beckenbaugh, MD 

Lawrence Bell, MD 

Keith Bengtson, MD 

Louis Benoist, MD 

Leon Benson, MD 

David Bierwagen, PT, CHT 

David Bikoff, MD 

David Billmore, MD 

David Birkbeck, MD 

Roderick Birnie, MD 

Allen Bishop, MD 

Donald Bittner, MD 

William Blair, MD 

Elizabeth Blake, MD 

Donna Blood, OTR/L, CHT 

Richard Bloomenstein, MD 

Leonard Bodell, MF 

Maria Bonazinga 

Michael Born, MD 

William Boss, MD 

Lawrence Bowen, MD 

David Bozentka, MD 

Timothy Bradley, MD 

Keith Brandt, MD 

Nancy Branz, PT, MS 

Laurence Brenner, MD 

Anthony Brentlinger, MD 

Bruce Brewer, MD 

James Brinkman, MD 

Garry Brody, MD 

Linda Brown, ND 

Mary Lynn Brown, MD 

Roger Brown, MD 

Robert Brumfield, MD 

Mark Buchman, MD 

Robert Buckley, MD 

Geoffrey Buncke, MD 

Gregory Buncke, MD 

Kim Buchstaber, OTR 

Rudolf Buntic, MD 

Mary Burns, OTR/L,CHT 

Christine Burridge, PT, CHT 

Vincent Butera, MD 

Marcia Buzzelli, PT, MS 

Carmine Calabrese, MD 

Elethea Caldwell, MD 

Catherine Calvey 

Michael Campbell 

Nancy Cannon, OTR, CHT 

David Caplin, MD 

James Carey, MD 

Ronaldo Carneiro, MD 

Ann Carrillo, OTR 

Glenn Carwell, MD 

Phyllis Chang, MD 

Wallace Chang, MD 

James Chao, MD 

John Chapple, MD 

Lawrence Chase, MD 

Andre Chaves, MD 

Eugene Cherny, MD 

Vradej Chinookoswong, MD 

Raj Chowdary, MD 

Robert Chuinard, MD 

Duke Chung, MD 

Michael Clark, MD 

Michael Clendenin, MD 

June Clopton, MD 

Tyson Cobb, MD 

Roberta Cohen, OTR 

Richard Coin, MD 

Larry Colen, MD 

Lee Colony, MD 

Charles Combs, MD 

Michelen Craft-Maynor 

Lester Cramer, MD 

Evan Crandall, MD 

Gregory Croll, MD 

Terry Cromwell, MD 

Robert Crow, MD 

Bohdan Czepak, MD 

Suman Das, MD 

Brian Davies, MD 

Bert Davis, MD 

Jayne Dederichs, OTR/L 

Fanny De le Cruz, MD 

A. Lee Dellon, MD

HONOR ROLL CON’T 

Heather Delp, LPT 

Jack Demos, MD 

Gloria DeOlarte, MD 

Michael DePriest, MD 

Robin De rose, OTR 

Robert Derkash, MD 

Sanjay Desai, MD 

Antonio DeSantolo, MD 

Susan DeStefano, OTR/L 

Gloria De Vore, OTR 

Gene Deune, MD 

Thomas DeWire, MD 

Prabhu Dhalla, MD 

Michal Diaz, MD 

Thomas DiBenedetto, MD 

Wayne Dickason, MD 

John Dietrich, MD 

Joseph Disa, MD 

Susan Doehr, OTR 

Sam Dovelle, OTR 

Gregory Dowbak, MD 

David Drake, MD 

John Drewniany, MD 

Marc Drimmer, MD 

Gale DuPont, OTR/L 

William Dzwierzynski, MD 

Janice Eaton, OTR/L, CHT 

Charles Eaton, MD 

Herbert Ecker, MD 

Lee Edstrom , MD 

Robert Ellis, MD 

James Esch, MD 

Gregory Evans, MD 

John Faillace, MD 

John Fatti, MD 

Bohdan Fedczuk, MD 

Harodl Fenner, MD 

Mciahel Ferdinands, MD 

John Finley, MD 

David Fischer, MD 

Gregory Fisher, MD 

Stephen Fisher, MD 

David Fitz, MD 

Richard Flaherty, MD 

Sandra Fletchall, OTR CHT, MPA 

Michael Flood, MD 

Waldo Floyd, MD 

Martin Fox, MD 

Paul Fragner, MD 

Arnis Freiberg, MD 

Scott Fried, MD 

Jeff Friedman, MD 

Mia Fuller, MS, OTR, CHT 

Stephen Fuller, MD 

Gerard Gabel, MD 

Unmeshchandra Gadaria, MD 

Sylvia Gagnon, MD 

Paula Galaviz, OT 

Randi Galli, MD 

Peter Galpin, MD 

Greg Ganske, MD 

Carlos Garcia Moral, MD 

Walter Garst, MD 

William Garvin, MD 

Shelai Gassler, OTR, CHT 

Trenton Gause, MD 

Eusebio Gaw, MD 

Michael Genoff, MD 

Margaret Geringer, OTR 

Gunter Germann, MD 

Royal Gerow, MD 

Marilyn Giln, OTR, CHT 

Terry Fillian, MD 

Kenn Given, MS 

Lawrence Glassman, MD 

Shellye Godfrey, OTR/L, CDE, CHT 

Alan Gold, MD 

Nelson Godlberg, MD 

Stephen Goldstein, MD 

Gregg Godnstrom, MD 

Federico Gonzalez, MD 

Marc Gottlieb, MD 

Joel Grad, MD 

Wendell Gray, MD 

Lawrence Gray, MD 

Daniel Greenwald, MD 

Jack Greider, MD 

John Griggs, MD 

John Grossman, MD 

Gail Groth, OTR/L, CHT, MHS 

Amit Gupta, MD 

Roxanne Guy, MD 

Mutaz Habal, MD 

Jane Haher, MD 

Paul Haiduk, MD 

Geoffrey Hallock, MD 

Michael Halls, MD 

Yousif Hamati, MD 

Robert Hansen, MD 

Paul Harkins, MD 

Richard Harkness, MD 

William Hart, MD 

Thomas Harter, MD 

David Haskell, MD 

Christopher Hauge, MD 

Chester Haverback, MD 

Robert Havlik, MD 

Tom Hayakawa, MD 

John Heieck, MD 

Darrell Henderson, MD 

Douglas Hendricks, MD 

Karen Henehan, MD 

Charles Hergrueter, MD 

Ralph Herms, MD 

Gregory Hill, MD 

Blayne Hirche, MD 

Christine Hoban, OTR, CHT 

Leslie Holcombe, OTR, CHT 

Ellen Horvitz, MS, PT, CHT 

Barney Horvath, MD 

Arden Hothem, MD 

Homer House, MD 

Patrick Houvet, MD 

Lon Howard, MD 

Pamela Howard, PT 

Richard Howard, MD 

David Huang, MD 

Mary Hubbell, CHT, CWCE 

William Huffaker, MD 

Edward Hughes, Jr., MD 

Thomas Hunt, MD 

Kenneth Hunter, MD 

Mary Isaacson, OTR 

Cindy Ivy, CHT 

Deborah Jacob-Maas 

Marshall Jemison, MD 

Chet Janecki, MD 

Raymond Janevicius, MD 

David Janssen, MD 

M.R. Jayasanker, MD 

David Jensen, MD 

Theron Jernigan, PT 

Stiles Jewett, MD 

Craig Johnson, MD 

Susan Johnson-Melat, OTR, CHT/CVE 

5 

William Jones, MD 

Jesse Jupiter, MD 

Ramasamy Kalimuthu, MD 

Loree Kalliainen 

Ann Kammien, PT 

Shin Kang, MD 

Reza Karimipour, MD 

Scott Kasden, MD 

Martin Kassan, MD 

Joanne Kassimir, CHT, OTR 

Richard Katz, MD 

Mark Kehn, MD 

Patrick Kelly, MD 

Mark Kendall, MD 

Carolyn Kerrigan, MD 

Martin Kessler, MD 

Lawrence Ketch, MD 

Roger Khouri, MD 

Suheil Khuri, MD 

Kyo Kim, MD 

Myung Kim, MD 

Woo-Kyung Kim, MD 

Yong Kim, MD 

Charles Kincaid, MD 

Gabriel Kind, MD 

Eugene King 

Lynn King, OTR, CHT 

John Kitzmiller, MD 

Howard Klein, MD 

Richard Knauft, MD 

Todd Koch, MD 

Richard Korentager, MD 

Bruce Kraemer, MD 

David Kupfer, MD 

Mine Kurtay, MD 

Stuart Kuschner, MD 

Joe Kutz, MD 

Jean Labelle, MD 

Daniel Labs, MD 

Juanita Laflin, CST 

John Lamana, MD 

Lauren Lancaster 

Richard Landry, MD 

Ann Lang, MA, OTR, CHT 

Edward Lanigan, MD 

Mary Beth Laplant, LPT 

Donald Leatherwood, MD 

Peter Ledoux, MD 

Charles Lee, MD 

Hans Lee, MD 

Howard Lee, MD 

James Lehman, MD 

Charles Leinberry, MD 

Lori Lenef, OTR/L 

Carl Lentz, MD 

Malcolm Lesavoy, MD 

Mark Leslie, MD 

John Lettieri, MD 

Scott Levin, MD 

Richard Levin, MD 

George Levine, MD 

Carolyn Levis, MD 

Jonathon Lewis, MD 

Terry Light, MD 

Peter Linden, MD 

John Lindsey, MD 

Charles Loguda, MD 

Linda Loya, MA, OTR,CHT 

Karen Luckett, OTR, CHT 

Steven Macht, MD 

Joy MacDermid, MD 

Douglas Mackenzie, MD 

Larry Maddy, RN, OTR/L, CHT 

Alexander Majidian, MD 

Matthew Malerich, MD 

Parvaiz Malik, MD 

Stephen Maloff, MD 

Christopher Maloney, MD 

Harold Mancusi-Ungaro, MD 

Mark Mandel, MD 

John Mara, MD 

Hallene Maragh, MD 

Norberto Marfori, MD 

Andrew Markiewitz, MD 

James Marshall, MD 

Kenneth Marshall, MD 

David Martin, MD 

Rosendo Martinez, MD 

Nalin Master, MD 

Howard Matsuba, MD 

William Mayhall, MD 

Alexander McArthur, MD 

John McAvoy, MD 

Steven McCabe, MD 

Thomas McChesney, MD 

Pamela McFarlane, MA, OTR, CHT 

John McGill, MD 

Nancy McHugh, OTR/L 

Craig McKee, MD 

Mehul Mehta, MD 

Keith Melancon, MD 

Mark Melhorn, MD 

Charles Melone, MD 

Jayasanker Menon, MD 

Craig Merrell, MD 

Wyndell Merritt, MD 

Louis Mes, MD 

Philip Metz, MD 

Claudia Meuli-Simmen, MD 

John Miller, MD 

Fred Miller, MD 

Norbert Ming, MD 

Sinesio Misol, MD 

Jose Monsivais, MD 

Carlos Montero, MD 

Kenneth Moore, MD 

William Moore, MD 

Seid Moosavi, MD 

Thomas Mordick, MD 

Richard Morgan, MD 

Donald Morris, MD 

Stephen Morris, MD 

Robert Morrison, MD 

Keith Morrison, MD 

Robert Morrow, MD 

Kenneth Murray, MD 


Eid Mustafa, MD 

Stephen Naso, MD 

Chet Nastala, MD 

Peter Nathan, MD 


Andrew Newman, MD 

Frank Newman, MD 

Mary Lynn Newport, MD 

William Nickell, MD 

Thomas Nipper, MD 

Christine Novak, MD 

Renee O’Sullivan, MD 

William Ogden, MD 

Walter Okunski, MD 

Elizabeth Ouellette, MD 

Winston Parkhill, MD 

Douglas Parks, MD 

Samuel Parry, MD 

Jay Patel, MD

HONOR ROLL CON’T 

Norman Payea, MD 

Shirley Pearson, OTR, MS 

Edward Pechter, MD 

William Pederson, MD 

Joseph Perlman, MD 

James Pertsch, MD 

Mary Son Pesco, MD 

Donald Pfeiffer, MD 

Howard Philips, MD 

Guy Pierret, MD 

Alan Pillersdorf, MD 

Jean Pilllet, MD 

James Pinkham, MD 

Miguel Pirella-Cruz, MD 

Subbarao Polineni, MD 

Jay Pomerance, MD 

Barry Poole, OTR, CHT 

Rasa Poorman, OTR, CHT 

Edward Powers, MD 

Julian Pribaz, MD 

George Primiano, MD 

Sergio Proserpi, MD 

Talmage Raine, MD 

Oscar Ramirez, MD 

Lorna Ramos, MA, OT 

James Raphael, MD 

Georg Rappold, MD 

Gregory Rauscher, MD 

Vincent Reale, MD 

Larry Reaves, MD 

Michael Reed, MD 

Loka Reddy, MD 

David Rehak, MD 

Michael Rench, MD 

Kevin Renfree, MD 

Charles Renner, OTR 

Charles Resnick, MD 

William Reus, MD 

Mary Reuterfors, MA, OTR, CHT 

Scott Riley, MD 

William Riley, Jr., MD 

Jeff Robb, MD 

Bradford Roberg, MD 

Dwight Roberson, MD 

Craig Roberts, MD 

Celia Robinson, MA, PT, CHT 

John Robinson, MD 

Alfredo Rodriguez, MD 

Frank Rogers, MD 

Allen Rosen, MD 

Arthur Rosenstock, MD 

Douglas Ross, MD 

Malcolm Roth, MD 

Eric Rothenberg, MD 

Paul Rottler, MD 

Leo Rozmaryn, MD 

Ronald Rusko, MD 

Robert Russell, MD 

Scott Sagerman, MD 

Harilaos Sakellarides, MD 

Chester Sakura, MD 

Jeffrey Salomon, MD 

Mona Samaan 

Alejandro Sanchez, MD 

Richard Sanders, MD 

Gordon Sasaki, MD 

Sandra Saunders, RPT, PT, CHT 

Robert Savage, MD 

Linda Schaffstall, OTR/L, CHT 

John Schantz, MD 

James Scheu, MD 

Kenneth Schiffman, MD 

Will Schlaff, MD 

Linda Schoenhals, MS, RPT 

Anne Schofield, OTR/L,CHT 


Frank Schuler, MD 

Karen Schultz, MS, OTR, CHT 

Timothy Schurman, MD 

John Seaberg, MD 

Kristin Seabol, MD 

Houshang Seradge, MD 

Donald Serafin, MD 

Jacob Sharp, MD 

Jay Shenaq, MD 

Saleh Shenaq, MD 

Randolph Sherman, MD 

Kenneth Shestak, MD 

Sung Shin, MD 

Raymond Shively, MD 

J.F. Showalter, MD 

Aamir Siddiqui, MD 

Jessica Siegers, OTR/L 

Maria Siemionow, MD 

Roger Simpson, MD 

Martin Skie, MD 

Joesph Slade, MD 

Paul Slater, MD 

Anthony Smith, MD 

Dell Parker Smith, MD 

Raymond Smith, MD 

Bendy So, MD 

Roger Sobel, MD 

Norman Sogioka, MD 

Raj Sood, MD 

Dean Sotereanos, MD 

John Sparrow, MD 

Jerome Spivack, MD 

T. Sreecharana, MD 

James Stafford, MD 

William Starr, MD 

J. Stayman, MD 

Scott Steinmann, MD 

Charlene Stennett, MD 

Peter Stern, MD 

Michael Sternschein, MD 

Thomas Stevenson, MD 

Curtis Steyers, MD 

Harold Stokes, MD 

Mary Stoliker, MS, OTR, CHT 

Tristan Stronger, MD 

Kevin Strathy, MD 

Berish Strauch, MD 

William Strinden, MD 

Chi-Tsung Su, MD 

John Swinburne, MD 

Raymond Takahashi, MD 

John Taras, MD 

Julia Terzis, MD 

Howard Tepper, MD 

Ben Thebaut, MD 

Lawrence Thompson, MD 

Grant Thomson, MD 

James Thornton, MD 

Jennifer Thurn, OTR, CHT 

David Toivonen, MD 

Bruce Topol, MD 

Steven Topper, MD 

Allen Tracy, MD 

Richard Troiano, MD 

Deborah Trojanowski, MD 

Thomas Trumble, MD 

Robert Tucker, MD 

Tsu Tsai, MD 

Christopher Ubinger, MD 

6 

Joseph Upton, MD 

James Urbaniak, MD 

Frederick Valauri, MD 

Napoleon Valdez, MD 

David Van Brunt, MD 

Robert Van Demark, MD 

Peter Van Giesen, MD 

Scott Vann, MD 

Benjamin Van Raalte, MD 

George Veasy, MD 

Tina Veraldi, OTR, CHT 

Nicholas Vienowicz, MD 

Charles Verheyden, MD 

Jeffrey Visotsky, MD 

Thomas Von Gillern, MD 

Frank Walchak, MD 

Lorenzo Walker, MD 

William Wallace, MD 

Madlyn Walton, OTR, CHT 

Robert Walton, MD 

Huan Wang, MD 

Robert Wanless, MD 

Robert Waterhouse, MD 

Paul Wavak, MD 

Burton Weber, MD 

Donald Wehmeyer, MD 

Larry Weinstein, MD 

Beth Weiss, OTR 

Mark Wells, MD 

Terry Westfield, MD 

Linda Westphal, OTR/L 

Michael Wheatley, MD 

John Wheeler, MD 

Nick Wheeler, MD 

Richard Whipple, MD 

Carolyn White 

David White, MD 

Richard White, MD 

David Whiteman, MD 

Robert Wilcox, MD 

Brandon Wilhelmi, MD 

Carl Williams, MD 

Barbara Winthrop-Rose, OTR, CHT 

Edward Withers, MD 

Eugene Wittenstrom, MD 

David Witzke, MD 

Levent Yalcin, MD 

Scott Young, MD 

John Yousif, MD 

William Zamboni, MD 

Jerrold Zeitels, MD 

Michael Zenn, MD 

D. Ziarkowski-Herb, PT, CHT 

Paul Zidel, MD 

Richard Zienowicz, MD 

Elvin Zook, MD

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. 


Robert Spinner, MD, Chairperson 

Joseph Rosen, MD 

Nash Naam, MD 

Ivica Ducic, MD, PhD 

David Netscher, MD 

Melanie Urbanchek, PhD 

Peter Evans, MD 

David Weinstein, MD, PhD 

Nancy McKee, MD, FRCSC 


Martijn Malessy, MD, PhD 

Robert Tiel, MD 

Rajiv Midha, MD, Ex-Officio 

MEMBERSHIP COMMITTEE 

Gregory R. D. Evans, MD, FACS, Chairperson 

Howard M. Clarke, MD, PhD 


Warren Hammert, DDS, MD 



Maria Siemionow, MD, PhD, Chairperson 

Allan Belzberg, MD 



Jonathan Winograd, MD 

Steven McCabe, MD, Ex-Officio 

BYLAWS COMMITTEE 

Melanie Urbanchek, PhD, Chairperson 

Paul Cederna, MD 

Loree Kalliainen, MD 

William Kuzon, MD, PhD 


Rajiv Midha, MD, Ex- Officio 


Robert Russell, MD, Chairperson 


Thomas Tung, MD 


TECHNICAL EXHIBITS COMMITTEE 

Gregory R. D. Evans, MD, FACS, Chairperson 

William Kuzon, MD, PhD 




Dimitri Anastakis, MD, Chairperson 

A. Lee Dellon, MD 



TIME AND PLACE COMMITTEE 

Robert Russell, MD, Chairperson 

Maria Siemionow, MD, PhD 

Gregory R. D. Evans, MD, FACS 


Steven McCabe, MD 

Rajiv Midha, MD 





Ivica Ducic, MD, PhD 

NEWSLETTER COMMITTEE 

Nash Naam, MD, Editor 

Robert Spinner, MD, Assistant Editor 

Christine Novak, PT, MS, Assistant Editor 

WEB SITE COMMITTEE 

Paul Cederna, MD, Chairperson 

David Brown, MD, FACS 


CODING AND REIMBURSEMENT COMMITTEE 

Keith Brandt, MD 

8

ASPN HISTORICAL INFORMATION 

FOUNDING COUNCIL (Established April 19, 1990) 

Warren Breidenbach, MD 

Thomas Brushart, MD 

David Chiu, MD 


Richard Ehrlichman, MD 

Nelson Goldberg, MD 


Howard Klein, 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 


Julia K.Terzis, MD, PhD 


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 

L. Scott Levin, MD, FACS 

AD HOC BREAST COMMITTEE 

Joseph M. Serletti, MD, FACS, Chairperson 

Elisabeth K. Beahm, MD 

Neil A. Fine, MD, FACS 

Maurice Nahabedian, MD 

Geoffrey L. Robb, MD 

Aldona J. Spiegel, MD 

Michael R. Zenn, MD 

AD HOC COMMITTEE ON COMPLEX 

RECONSTRUCTION 

Fu-Chan Wei, MD, FACS, Chairperson 

Lawrence B. Colen, MD 


William C. Pederson, MD 

Julian J. Pribaz, MD 

Milan Stevanovic, MD 

AD HOC COMMITTEE ON COMPOSITE 

TISSUE ALLOTRANSPLANTATION 

Robert L. Walton, MD, FACS, Chairperson 


Neil F Jones, MD 


Susan E. Mackinnon, MD 

Maria Siemionow, MD, Ph.D. 


Fu-Chan Wei, MD, FACS 

AD HOC COMMITTEE ON GENITOURINARY 

RECONSTRUCTION 

Lawrence B. Colen, MD, Chairperson 

Charles E Butler, MD 

David W. Chang, MD 

AD HOC HEAD & NECK 

SUBSPECIALITY COMMITTEE 

Peter G. Cordeiro, MD, Chairperson 

Lawrence J. Gottlieb, MD 

Michael Miller, MD 


AD HOC LOWER EXTREMITY 

SUBSPECIALITY COMMITTEE 

L. Scott Levin, MD, FACS, Chairperson 

Christopher Attinger, MD 

Marko Bumbasirevic, MD 

Raymond M. Dunn, MD 

AD HOC MEDIA RELATIONS COMMITTEE 

L. Scott Levin, MD, FACS, Chairperson 


Allen L. Van Beek, MD 

AD HOC MICROSURGICAL 

RESEARCH COMMITTEE 

Maria Siemionow, MD, PhD, Chairperson 



Peter C. Neligan, MD 


AD HOC OUTREACH COMMITTEE 

Randy Sherman, MD, Chairperson 



Robert C. Russell, MD 


AD HOC UPPER EXTREMITY 

SUBSPECIALTY COMMITTEE 

Nicholas B. Vedder, MD, Chairperson 



Jonathan Isaacs, MD 


ASPS BOARD REPRESENTATIVE 

Robert L. Walton, MD, FACS 

AUDIT COMMITTEE 

Jeffrey D. Friedman, MD, Chairperson 



BUNCKE LECTURESHIP COMMITTEE 

William C. Pederson, MD, Chairperson 




G. Ian Taylor, AO, FRACS, FACS FRCS 


BYLAWS COMMITTEE 

Julian J. Pribaz, MD, Chairperson 

Gregory M. Buncke, MD 

Anthony A. Smith, MD 

CLINICAL GUIDELINES 

& OUTCOMES COMMITTEE 

Nicholas B. Vedder, MD, Chairperson 

Howard N. Langstein, MD 



11

ASRM COMMITTEES CON’T 

CPT/RUC COMMITTEE 

Keith E. Brandt, MD, Chairperson 


Raymond M. Dunn, MD 

Daniel J. Nagle, MD 

Scott D. Oates, MD 




Howard N. Langstein, MD, Chairperson 

Paul S. Cederna, MD, FACS 



ELECTRONIC COMMUNICATIONS 

COMMITTEE 

Charles E Butler, MD, Chairperson 

Keith E. Brandt, MD, Ex-Officio 

William Dzwierzynski, MD 



ENDOWMENT COMMITTEE 

Robert L. Walton, MD, FACS, Chairperson 

Keith E. Brandt, MD 

Joseph James Disa, MD 

William A. Zamboni, MD 



Keith E. Brandt, MD, Ex-Officio 

Frederick J. Duffy, Jr, MD 

Joseph M. Serletti, MD, FACS 

GODINA FELLOWSHIP 

SELECTION COMMITTEE 


Zoran M. Arnez, MD, PhD 




MEMBERSHIP COMMITTEE 


A. Lee Dellon, MD, Ex-Officio 


Gabriel M. Kind, MD 





Allen T. Bishop, MD 



Robert C. Russell, MD 


Michael R. Zenn, MD, Chairperson 

Joseph M. Serletti, MD, FACS, Ex-Officio 




Gabriel M. Kind, MD 

Alexander Y. Shin, MD 


Joseph Upton, MD 

PSEF REPRESENTATIVE 

Gregory R.D. Evans, MD, FACS 

TECHNICAL EXHIBITS COMMITTEE 

Peter C. Neligan, MD, Chairperson 


William Lineaweaver, MD 

TIME & PLACE COMMITTEE 



Ronald M. Zuker, MD, FRCSC 

12

ASRM HISTORICAL INFORMATION 

1983 FOUNDING COUNCIL 

James B. Steichen, 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 


1987 Joseph E. Kutz, MD San Antonio, TX Robert D. Acland, MD 


1988 H. Bruce Williams, MD Baltimore, MD Berish Strauch, MD 


1989 James B. Steichen, MD Seattle, WA G. Ian Taylor, FRCS, FRACS 


1990 Allen L. Van Beek, MD Toronto, Ontario, Canada Andrew Lightbody 


1991 Michael B. Wood, MD Orlando, FL Alain Gilbert, MD 


1992 Andrew J. Weiland, MD Scottsdale, AZ Edgar Biemer, MD 


1993 Graham Lister, MD Kansas City, MO Algimantas Narakas 



Godina Lecturer 

1994-95 Robert C. Russell, MD Marco Island, FL Nguyen Huy Phan, MD 


Mark A. Schusterman, MD 


1995-96 Ralph T. Manktelow, MD Tucson, AZ Fu Chan Wei, MD 


Randy Sherman, MD 


1996-97 James A. Nunley, MD Boca Raton, FL James R. Urbaniak, MD 


Zoran M. Arnez, MD 


1997-98 William M. Swartz, MD Scottsdale, AZ H. Bruce Williams, MD 


L. Scott Levin, MD 


1998-99 David T. W. Chiu, MD Waikoloa, HI Julia K. Terzis, MD 


Phillip Blondeel, MD 


1999-2000 Daniel Nagle, MD Miami, FL Allen Van Beek , MD 


Gregory R. D. Evans, MD 


2000-2001 Saleh M. Shenaq, MD San Diego, CA Wayne Morrision, MD, FRACS 




2001-2002 Randy Sherman, MD Cancun, Mexico Robert Russell, MD 




2002-2003 Julia K. Terzis, MD, PhD Kauai, HI Panayotis Soucacos, MD 


Raymond Dunn, MD 


2003-2004 Ronald M. Zuker, MD Palm Springs, CA Ralph Manktelow, MD 


Milomir Ninkovic, MD, PhD 


2004-2005 Robert L. Walton, MD, FACS Fajardo, Puerto Rico Isao Koshima, MD 


Michael Neumeister, MD, FRCSC, FACS 


2005-2006 William C. Pederson, MD Tucson, AZ David Chang, MD, FACS 


13

MESSAGES FROM THE PROGRAM CHAIRS 

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 

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 interactions 

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 attractions 

on the island. 

All in all, this meeting promises to be a memorable experience. 

Robert J. Spinner, M.D. 

ASPN 2007 Program Chair 

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 



ASRM

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, neurosurgery 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 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 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 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. 

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 popular 

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 

PLASTIC SURGEONS 

Booth: 23 

Emily Matzelle 

American Society of Plastic Surgeons 

444 East Algonquian Rd. 

Arlington Heights, IL 60005 

Phone- 847-228-9900 fax- 847-981-5482 

email- ejm@plasticsurgery.org 

website- www.plasticsurgery.org 

The American Society of Plastic Surgeons is the largest organization of board-certified 

plastic surgeons in the world. With 6,000 members, the society is recognized as a leading 

authority and information source on cosmetic and reconstructive plastic surgery. The society 

represents physicians certified by The American Board of Plastic Surgery or The Royal 

College of Physicians and Surgeons of Canada. 

ANATOMY GIFTS REGISTRY 

Booth: 33 

Brenda Bardsley 

7522 Connelley Drive, Suite P 

Hanover, MD 21076 

phone- 410-553-0525 fax-410-553-0502 

email- info@anatomicgift.com 

website- www.anatomicgift.com 

Anatomy Gifts Registry is a non-profit Donor Registry specializing in procurement, preservation 

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 

on specimen availability or application please call (410) 553-0525 or e-mail 

info@anatomicgift.com. 

ANGIOTECH (FORMERLY SURGICAL SPECIALTIES CORPORATION) 

Booth: 34 

Erika Fry 

100 Dennis Drive, Reading, PA 19606 

Phone- 610-404-1000 fax- 610-404-2061 

e-mail- efry@angio.com 

website- www.angiotech.com / www.surgicalspecialties.com 

Angiotech, formerly Surgical Specialties Corporation, features a wide rage of Sharpoint® 

micro-sutures and microsurgical knives – designed to meet the specific demands of the 

micro-surgeon. They also offer micro-training materials including: manuals, non-sterile 

sutures and PracticeRat. Stop by our booth and take a macro view of your full line micro 

company. 

APTIS 

Booth: 14 

Barbara Chesher 

5 River Hill Rd., Louisville, KY 40207 

phone- 502-561-4240 fax-502-585-0009 

email- barabrac@aptismedical.com 

website- www.anatomicgift.com 

APTIS MEDICAL specializes in taking current concepts to the next level. With the success 

of the Scheker DRUJ prosthesis, Aptis has provided a product that totally replaces the 

DRUJ, prevents subluxation and allows the bearing of weight. Other new and innovated 

designs for joint replacement are soon to follow 

ASCENSION ORTHOPEDICS 

Booth: 9 

Patsy Peterson 

8700 Cameron Rd., #100 

Austin, TX 78723 

phone- 512-836-5001 fax-512-836-5145 

email- ppeterson@ascensionortho.com 

website- www.ascensionortho.com 

Ascension Orthopedics is dedicated to the research, development, manufacture and distribution 

of revolutionary orthopedic devices for the hand, upper extremity, and foot. The 

company founders are pioneers in the material science to combat the debilitating effects 

of arthritis. 

17 

ASSI 

Booth: 20 

Proud sponsor of the ASRM International Reception 

Marie Bonazinga 

300 Shames Drive, Westbury, NY 11590 

phone- 516-333-2570 fax-516-997-4948 

email- cbowen@accuratesurgical.com 

website- www.accuratesurgical.com 

ASSI will feature the Engler Breast Retractor, the Stanger C Brest Retractors and the new 

Lalonde Breast Sizers, the Lalonde Percutaneous Bone Clamp with K-wire guide, Face Lift 

Retractors, Campbell Lip Awl, Matarasso Lipo Roller and SuperCut Face Lift Scissors, ASSI’s 

Bipolar Scissors, Micro Monopolar Forceps, the Surex Sural Nerve Extractor and Nerve 

Holding/Cutting Forceps. ASSI’s Hand Crafted Microsurgical Instruments and Clinical 

Microvascular Clamps. 

BIOMET TRAUMA 

Booth: 1 

Charlie Eaton 

100 Interpace Pkwy., Parsippany, NJ 7054 

phone- 973-299-9300 fax-973-299-0391 

email- charlie.eaton@ebimed.com 

website- ebimed.com 

Biomet-New Jersey (formerly EBI, L.P.) develops and markets a full range of internal and 

external orthopedic devices used in fracture fixation of the upper extremity. This includes 

the OptiLock Distal Radius Plating System, Uniflex Humeral Nail and a variety of distal 

radius fixators. 

BME 

Booth: 11 

Lisa May 

Marketing Specialist 

14785 Omicron Dr., #205, San Antonio, TX 78245 

Phone- 800-880-6528 fax- 210-677-0355 

email- lisamay@BME-tx.com 

website- www.bme-tx.com 

COOK MEDICAL 

Booth: 19 

Rachel Barnhill 

750 Daniels Way, Bloomington, IN 47404 

phone- 812-339-2235 fax-812-339-3704 

email- rachel.barnhill@cook-inc.com 

website- www.cookmedical.com 

Cook® presents two unique products: The Cook-Swartz implantable Doppler Blood Flow 

probe with new DP-M250 Monitor offering the latest technology for continuous confirmation 

of vascular patency. Surgisis®, an absorbable porcine small intestinal submucosa 

biomaterial that provides a scaffold for host tissue remodeling, creating a natural, costeffective 

alternative to surgical repair. 

DVO 

Booth: 3 

Rachel Bushong 

720 East Winona Ave., Warsaw, IN 46580 

phone- 877-777-9382 fax-574-258-1542 

email- rachel.bushong@dvosolutions.com 

website- www.dvosolutions.com 

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 contains 

our Dorsal IM Plate and Intrafocal Pin Plate. 

HOLOGIC, INC. 

Booth: 10 

Nicole Athanas 

35 Cosby Drive, Bedford, MA 1730 

phone- 781-999-7342 fax-781-280-0668 

email- nathanas@hologic.com 

website- www.hologic.com 

Fluoroscan® mini C-arm X-ray systems from Hologic are designed for orthopedic surgeons 

performing minimally invasive surgical procedures of the extremities, as well as for lowdose, 

in-office imaging.

HAND SURGERY ENDOWMENT 

Booth: TABLE TOP 

Laura Downes Leeper, CAE 

20. N. Michigan Ave., Suite 700 

Chicago, IL 60602 

Phone- 312-236-3307 

email- downes@isms.org 

The Hand Surgery Endowment supports education and research to improve patient care 

and safety of the hand and upper extremities. The Endowment funds scholarships and 

awards; public awareness, research projects and AAHS strategic initiatives that promote 

optimal hand and upper extremity health and safety. 

INTEGRA 

Booth: 29 

Proud sponsor of the ASPN Invited Speakers 

Jon Trout 

311 Enterprise Dr., Plainsboro, NJ 8536 

Phone- 609-275-0500 fax- 609-799-3297 

e-mail- jtrout@integra-ls.com 

website- www.integra-ls.com 

Integra develops, manufactures, and markets medical devices for neuro-trauma and neurosurgery, 

plastic and reconstructive surgery and general surgery. Integra’s peripheral 

nerve surgery products include NeuraGen for completely severed nerves and 

NeuraWrap for compressed, scarred or partially injured nerves. 

KINETIKOS MEDICAL INC./KMI 

Booth: 28 

Danielle Macrorie 

6005 Hidden Valley Rd., Suite 180 

Carlsbad, CA 92011 

Phone- 760-448-1700 ext.1422 fax- 760-448-1739 

e-mail- dmarcrorie@visitkmi.com 

MED LINK USA 

Booth: 30 

Tod Kellen 

PO BOX 42483, Des Moines, IA 50323 

Phone- 800-762-7921 fax- 800-329-5990 

e-mail- tkellen@medlinkusa.com 

website- www.medlinkusa.com 

Proud sponsor of the Cyber Cafe 

MEDARTIS 

Booth: 6 

Erin Graybill 

127 W. Street Road, Suite 203, Kennett Square, PA 19348 

Phone- 610-961-6101 fax- 610-961-6108 

e-mail- erin.graybill@medartis.com 

website- www.medartis.com 

Medartis is committed to providing surgeons and operating theatre personnel in orthopedic 

and cranio-maxillofacial surgery with innovative implants, instruments and services 

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 surgeons, 

scientists, universities and hospitals 

MICRINS SURGICAL 

Booth: 31 

Bern Teitz 

28438 Ballard Dr., Lake Forest, IL 60048 

Phone- 847-549-1410 fax- 847-549-1510 

e-mail- bern@micrins.com 

Micrins Features well over 3500 different instruments and accessories for Aesthetic, Hand, 

Micro and Reconstructive Surgery. Our product offering includes: The Micrins® brand of 

Hand Held Surgical Instruments, Razor-Edge Scissors, and Genuine Stille Surgical 

Instruments. The Micrins booth is conveniently located in the center of the exhibit hall. 

18 

MICROSURGERY INSTRUMENTS, INC 

Booth: 16 

Nancy Kang 

7211 Regency Sq. Blvd #223, Houston, TX 77036 

Phone- 713-664-4707 fax- 713-664-8873 

e-mail- mirriusa@microsurgeryusa.com 

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 

number of surgical fields including: Orthopedics, Plastic Surgery, Hand Surgery, ENT, 

Urology, General Surgery, Neurosurgery, and in many other more fields. 

NDI 

Booth: 18 

Jim Gabriel 

One Chagrin Highlands, 2000 Auburn Dr., Ste 320, Cleveland, OH 44122 

Phone- 216-378-9106 fax- 216-378-9116 

e-mail- jgabriel@ndimedical.com 

website- www.ndimedical.com 

NDI Medical is a neurostimulation medical device company. The Checkpoint stimulator 

is a surgical tool that provides surgeons with a reliable method of applying electrical stimulation 

to exposed motor nerves and muscle tissue to locate and identify nerves. The 

variable parameters provide reliable feedback while testing nerve and muscle excitability. 

NEXA ORTHOPEDICS 

Booth: 13 

Patricia Dorgan 

Marketing Services Manager 

11035 Roselle Street, San Diego, CA 92121 

Phone- 800-835-8480 fax- 858-866-0661 

e-mail- pdorgan@nexaortho.com 

website- www.nexaortho.com 

Nexa Orthopedics, the technology leader in products for reconstructive surgery of the 

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 

Radial Head systems. 

SMALL BONE INNOVATIONS 

Booth: 5 

Carolyn Desautels 

Global Meetings Manager 

1711 S. Pennsylvania Ave., Morrisville, PA 19067 

Phone- 215-428-1791 fax- 215-428-1805 

e-mail- cdesautels@totalsmallbone.com 

website- www.totalsmallbone.com 

Small Bone Innovations, Inc. (“SBI”) is focused on the needs of the small bone & joint 

surgeon resulting in surgeon designed and clinically proven products. SBI is continually 

expanding its portfolio to become the worldwide leader in the design, development, 

manufacture, and marketing of upper and lower extremity medical devices. 

SMITH AND NEPHEW 

Booth: 15 

Jennifer Waddell 

Educational Conference Coordinator Proud co-sponsor of the ASRM concert event. 

11775 Starkey Rd., Largo, FL 33773 

With an emphasis on customer-driven technology and innovation, our goal at Smith & 

Nephew is to continue anticipating the future of excisional debridement. VersaJet is a 

specialized fluid jet instrument that enables surgeons to easily grasp, cut and remove 

damaged tissue and contaminants from surgical, traumatic and chronic wounds and 

burns in a precise and safe manner.

SPRINGER 

Booth: TABLE TOP 

Acasia Dalmau 

233 Spring St., New York, NY 10013 

Phone- 212-460-1600 fax- 201-272-1832 

e-mail- exhibits-ny@springer.com 

website- www.springer.com 

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. 

STRYKER ORTHOPAEDICS 

Booth: 7 & 8 FOR AAHS 

AND 21 FOR JOINT 

Peter Valente 

325 Corporate Dr., Mahwah, NJ 7430 

Phone- 201-831-5276 fax- 201-831-6453 

e-mail- perter.valente@stryker.caom 

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 orthobiologic 

solutions for fracture treatment. Industry recognized product lines such as T2®, 

Hoffmann, Asnis III, Variax and Profyle Hand Products. 

SYNOVIS 

Booth: 24 & 25 

Britt Maganzini 

739 Industral Lane, Birmingham, AL 35211 

Phone- 205-941-0111 

e-mail- britt.maganzini@synovismicro.com 

Synovis MCA, “the microsurgeon’s most trusted resource,” provides innovative advancements 

and technologies for microsurgeons. The COUPLER and GEM MicroClips are precise 

instruments that help save valuable OR time and enable microsurgeons to perform 

highly effective anastomotic surgical procedures faster, easier and more dependably than 

traditional suture anastomosis. The GEM Neurotube® is an absorbable woven polyglycolic 

acid mesh tube designed for peripheral nerve repair and reconstruction. 

Introducing Veritas® Collagen Matrix, an advanced technology in soft tissue repair, saves 

time, is biocompatible and remodelable, has exceptional handling and comes in a variety 

of sizes. Biover Microvascular Clamps are disposable and produce a consistent measured 

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 

Booth: 2 

Lisa Kauffman 

1301 Goshen Parkway, West Chester, PA 19380 

Phone- 610-719-6873 fax- 610-719-6533 

e-mail- Kauffman.lisa@synthes.com 

website- www.synthes.com 

Proud sponsor of the Bottled Water 

and AAHS President’s Dinner 

Proud sponsor of the ASPN website and 

ASRM “Best Microsurgical Awards” 

Synthes CMF is the sole authorized North American manufacturer and distributor of AO 

ASIF instruments and implants for internal fixation of craniomaxillofacial and mandibular 

trauma and reconstruction. Our product offering includes distraction osteogenesis 

devices, resorbable plating, and bone graft substitutes. Synthes CMF also supports North 

American AO ASIF Continuing Education courses. 

19 

THE GUATEMALA HEALING 

HANDS FOUNDATION 

Booth: 12 

Mona Lipson 

290 6th Ave., Brooklyn, NY 11215 

Phone- 718-768-5927 

e-mail- monalipson@hotmail.com 

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 therapy. 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. 

THIEME PUBLISHERS 

Booth: 17 

Ross Lumpkin or Daniel Schiff 

333 Seventh Ave., New York, NY 10001 

Phone- 212-584-4706 fax- 212-947-1112 

e-mail- grace.eassese@thieme.com 

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. 

TRI MED, INC. 

Booth: 4 

Jim Fassett 

869 Main Street, Walpale, MA 2081 

Phone- 508-668-0988 fax- 508-668-0212 

e-mail- trimedortho@verizon.net 

website- www.trimedortho.com 

VIOPITIX, INC 

Booth: 26 

Denise Yarmlak 

44061-B Old Warm Springs Blvd., Fremont, CA 94538 

Phone- 510-226-5806 x 217 

e-mail- yarmlakd@vioptix.com 

The ViOptix Tissue Oximeter is a proprietary breakthrough product and technology that 

enables non-invasive, direct, real-time measurement of local tissue oxygen saturation. 

The ViOptix Tissue Oximeter is used in reconstructive flap surgeries and digit replantation 

to assess and monitor tissue viability post-operatively, thereby improving medical 

outcomes and decreasing cost.

AAHS CONTINUING MEDICAL EDUCATION 

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 


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 



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 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 theamerican Association for Hand Surgery. Any sound reproduction, transcript, or other use of material presented at the meeting without the permission 

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. 


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. 



medical education for physicians. The Plastic Surgery Educational Foundation® (PSEF®) is the clinical education arm of the ASPS. The PSEF designates this 


AAHS/ASRM/ASPN COMBINED DAY 


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 



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 statement 

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 material 

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 practitioners. 

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 development 

and exchange of knowledge pertaining to peripheral nerve regeneration; it does so only in the contest of a private forum without making any representations 

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. 


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. 


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. 



medical education for physicians. The Plastic Surgery Educational Foundation® (PSEF®) is the clinical education arm of the ASPS. The PSEF designates this 


AAHS/ASRM/ASPN Combined Day 


ASRM Master Series in Microsurgery 


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 Coruses 308 - 314 1.00 hour each 

Instructional Courses 315 - 321 


1.00 hour each 

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 without 

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 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 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 pertaining 

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. 


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. 


THE FOLLOWING PRESENTERS DID NOT SUBMIT DISCLOSURE DOCUMENTS: 

Prof. Xavier Navarro Acebes, MD, PhD 

Richard Berger, MD, PhD 

Richard E. Brown, MD 

Bernard Chang, MD 

David T. W. Chiu, MD 

Peter G. Cordeiro, MD 

Zoe Dailliana, MD 

Coleen Gately, MS, PT, DPT 

Ralph Gilbert, MD 

Tessa Gordon, PhD 

Michael R. Hausman, MD 

Joy MacDermid, PhD, PT 

Wyndell H. Merritt, MD 


Jorge L. Orbay, MD 



Matthew Putnam, MD 

Mark Rekant, MD 

David Ring, MD 

Teri Skirven, OTR/L, CHT 

Joseph Slade, III, MD 

Hans-Ulrich Steinau, MD 

Rebecca von der Heyde, MS, OTR, CHT 


Andrew Weiland, MD 

Aviva Wolff, OTR/L, CHT 

Jianguang Xu, MD, PhD 

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 


2008 ANNUAL MEETING 

January 9 - 12, 2008 

The Hyatt Century Plaza Hotel and Spa 

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. 


January 7 - 10, 2009 

Grand Wailea Resort Hotel and Spa 

Maui, Hawaii 


January 6 - 9, 2010 

Boca Raton Resort and Club 

Boca Raton, Florida 



January 12 - 13, 2008 




January 10 - 11, 2009 


Maui, Hawaii 


January 9 - 10, 2010 


Boca Raton, Florida 

24 



January 12 - 15, 2008 




January 10 - 13, 2009 


Maui, Hawaii 


January 9 - 12, 2010 


Boca Raton, Florida


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


Wednesday, January 10, 2007 

6:30am – 7:30pm Continental Breakfast with Exhibitors 

7:30am – 1:30pm Specialty Day Program: Rapid Recovery 

The Fast Track 

Experts will present the latest techniques to treat and 

rehabilitate your patient for fastest recovery following 

hand and wrist injuries. Hear how to get your 

athlete, work injured patient, or family friend back to 

work and play as quick as possible using new 

surgical and rehabilitation methods. Relative risks 

compared to more “traditional” methods will also be 

discussed. And, don’t forget to join us for a little 

side show of golf – test your skills and win a prize. 

Brian Adams, MD, Program Co-Chair 

Aviva Wolff, OTR/L, CHT, Program Co-Chair 

7:30am – 7:35am President’s Welcome 


7:35am – 7:45am Overview – “When Can Recovery be Rapid?” 



7:45am – 8:00am Outcomes - How Do We Measure 

Rapid Recovery? 

Joy Macdermid, PT, PhD, CHT 

Wrist Injuries: “The Express Line” 

Christine Novak, PT, Moderator 

8:00am – 8:10am Scaphoid Fractures 

Randall Culp, MD 

8:10am – 8:20am Distal Radial Fractures 

Jorge Orbay, MD 

8:20am – 8:35am Recovery After Wrist Fractures 

Dorit H. Aaron, MA, OTR/L, CHT, FAOTA 

8:35am – 8:55am Ligament Injuries 


Julianne Howell, PT, MS, CHT 

8:55am – 9:10am Panel/Discussion 

9:10am – 10:45am Digital Injuries – “Hold Fast” 

Brian Adams, MD, Moderator 

9:10am – 9:30am Metacarpal and Phalangeal Fractures 

Michael Bednar, MD 

Terri Skirven, MS, OTR/L, CHT 

9:30am – 9:50am PIP Fracture Dislocations 

Joseph Slade, MD 

Paul Brach, MS, PT, CHT 

9:50am – 10:10am Extensor Tendon Injuries 


Julianne W. Howell, MS, PT, CHT 

10:10am – 10:30am Flexor Tendon Injuries 

Peter Amadio, MD 

Rebecca von der Heyde, MS, OTR, CHT 

10:30am – 10:45 Panel/Discussion 

10:45am – 11:00am Break with Exhibitors 

Pediatric Injuries: “What Can We Learn From Kids?” 

11:00am – 11:20am Upper Extremity Fractures: Hand, Wrist 

and Forearm 


Dorit H. Aaron, MA, OTR/L, CHT, FAOTA 

Sports Injuries: “How the Athletes Do It – In a NY Minute” 

Susan Michlovitz, PT, PhD, CHT, Moderator 

26 

11:20am – 11:30am Surgical Treatment – When to fix, When to wait 

Andrew Weiland, MD 

11:30am – 11:40am Protective Gear – Rules, Regulations, 

Requirements 

Michelle Carlson, MD 

11:40am – 11:50am Methods of Protection – Splints, Padding 

Coleen Gately, MS, PT, DPT 

11:50am – 12:00pm Casting Techniques for Sports Activities 


12:00pm – 12:10pm The Injured Golfer 


Case Presentations: When Rapid is Not So Rapid 

12:10pm – 12:20pm My Experience with Firefighters 

Joy Macdermid, PT, PhD, CHT 

12:20pm – 12:30pm My Experience with the Not So Healthy Worker 

Susan Michlovitz, PT, PhD, CHT 

12:30pm – 12:40pm Rapid Recovery and Nerve Injury, an Oxymoron? 

Christine Novak, MS,PT, PhD(c) 

12:40pm – 1:00pm Panel/Discussion 

1:00pm – 1:30pm Rate Your Golf Swing against the Pro 

1:00pm – 5:00pm La Federacion del Mano Inaugural Meeting 

Eduardo Zancolli, III, MD 

Course is complimentary but pre-registration is required. 

3:30pm – 5:30pm Bioskills Workshops 

BW-I Current Techniques for PyroCarbon 

MCP/PIP/CMC Arthroplasty 

Course Description: Use of the Ascension MCP/PIP/PHS implants will be demonstrated 

in this workshop. The course is designed to provide a comprehensive overview of the 

PyroCarbon Implants, design rationale, patient selection, surgical technique and postoperative 

therapy. Cadaveric models will be used to demonstrate MCP/PIP/PHS implant 

insertion and soft tissue repair. 

Course Objectives: Participants should have an understanding of indication, proper 

technique and post operative therapy. 

Faculty: Robert Beckenbaugh, MD 

BW-2 Current Techniques for DRUJ Disorder 

Course Description: Use of the Ascension First Choice DRUJ System will be demonstrated 

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 

comprehensive overview of DRUJ disorders, discuss both implant options offered in the 

First Choice DRUJ System, the Partial Resurfacing implant and a Total Ulnar Head 

Implant, design rationale, patient selection, surgical technique and postoperative therapy. 

Cadaveric models will be used to demonstrate the surgical technique of both the 

Partial Resurfacing Implant and Total Ulnar Head Implant. 

Course Objectives: Participants should have an understanding of Indication, proper 

technique and post operative therapy. 

Faculty: Brian Adams, MD 

BW-3 Treatment of Distal Radius Fractures 

Course Description: There will be a surgical demonstration on the treatment of distal 

radius fractures using the OptiLock® Distal Radius Plating System with patented 

SphereLock TM technology. Emphasis will be on indications, design rationale, surgical technique, 

post-operative rehabilitation and follow-up. 

Faculty: Melvin P. Rosenwasser, MD 

BW-4 Open and Arthroscopic Treatment of the 

Thumb CMC Arthritis 

Course Description: A number of different methods can be successfully used for treatment 

of osteoarthritis of the CMC joint. This workshop will focus on strategies for the 

use of a minimally invasive approach to treat earlier stage OA utilizing a biodegradable 

resurfacing implant. 

Course Faculty: Randall Culp, MD 

BW-5 Minimal Resection Total Wrist Arthroplasty; 

Surgical Technique and Case Review 

Course Description: Reproducible positive results with total wrist arthroplasty rely heavily 

on the instrumentation and surgical technique. A new, anatomic wrist instrumentation 

system (and implant) will be presented, focusing on minimal bone resection and 

consistent results. 

Course Faculty: William Cooney, MD 

BW-6 Hand & Upper Extremity Solutions 

6:00pm – 7:00pm AAHS Welcome Reception 

See page 16 for details 

Sponsored by: 

Sponsored by: 

Sponsored by: 

Sponsored by: 

Sponsored by: 

Sponsored by:

SCAPHOID FRACTURES: RAPID RECOVERY – THE FAST TRACK 

RANDALL W. CULP, M.D. 

I. Epidemiology 

A. Among all wrist injuries, the incidence is second only to fractures of the distal radius fracture 6 

B. Approximately 345,000 scaphoid fractures per year in the U.S. 17 

C. Nearly 70% of carpal fractures involve the scaphoid 19 

D. Annual incidence in Denmark: 38 per 100,000 men, 8 per 100,000 women 18 

E. Average age group: 15-29 years 18 

F. Nonunion rate of 92% in fractures displaced < 1 mm 9 

G. Estimated that there are 17,250 to 34,500 nonunions per year despite proper treatment 20 

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 

d. 30 year follow up, 56 patients, 10% nonunion rate 8 

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 

motion (cadaver study) 15 

c. Inclusion of additional digits 

1) Dehne 7 

– inclusion of the index and middle finger 

2) Taleisnik 26 

– 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 

2. Rettig & Kollias 12-23 

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 

c. Yip, Wu, Chang, So 27 

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, Geissler 25 

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 

a. Rettig, Raskin 24 

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? 

A. Chan, McAdams 4 

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, 3 rd ; 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 mobilizing 

the proximal radius. It provides sufficient exposure to manage articular displacement, apply bone graft and treat nascent 

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 evaluated 

radiographically and functionally. The average final range of motion was 60 deg. of dorsiflexion, 58 deg. of volar flexion, 

82 deg. of pronation and 79 deg. of supination. The grip strength was 77% of the contralateral side. No external fixation 

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 minimizes 

tendon problems. 

32

References: 

Recovery after Wrist Fractures: 

Post Op Management of DRFx and Scaphoid Fx 

Dorit H. Aaron, MA, OTR, CHT, FAOTA 

AAHS PR 2006 

DHA2@aol.com 

Aaron DH, Stegink-Jansen CW (2000). Rehabilitation: Matching Patient Priorities & Performance with Pathology & 

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 

Extremity: 5 

Hand and Upper 

th 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 

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 longitudinal 

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 Sports Medicine.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 biomechanical 

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 configurations 

in transverse and oblique phalangeal fractures. Journal of Hand Surgery - American Volume.1988;2:246-53. 

37

Introduction 

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 

Joseph.slade@yale.edu 

“Rapid Recovery- The Fast Track” 

9:30-9:50AM 

AAHS 2007 ANNUAL MEETING 

PUERTO RICO 

Wednesday, January 10th, 2007 

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 phalanx. 

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 orthotic 

traction splint which permitted passive motion while applying continuous traction. This traction splint used ligamentotaxis 

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 ability 

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 fixator 

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 interface 

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 collateral 

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 extended 

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 sustained 

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 deforming 

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 


Hemi-Hamate Chondral Arthroplasty 


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 proximal 

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 complete 

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 distraction 

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 prevent 

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 radiographs 

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 distance 

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 isotonic 

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 concentration 

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

Core Sutures 

New Techniques for Flexor Tendon Repair in Zone 2 

Peter C. Amadio, MD 

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.” 


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-tendonrepair 

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 excursion 

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.” 


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 dha2@aol.com 

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 complications 

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 pediatrics. 

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 


Dorit H. Aaron, MA, OTR/L, CHT 

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 


Specialty Day 2007 

Rapid Recovery- The Fast Track 

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

References 

RAPID RECOVERY & NERVE INJURY: AN OXYMORON? 

Rapid Recovery – The Fast Track 


January 10, 2007 

Christine B. Novak, PT, MSc, PhD(c) 

University Health Network, Toronto, Ontario 

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. Clinical Neurophysiology 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. Neurology 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



Thursday, January 11, 2007 


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


Thursday, January 11, 2007 

6:30am – 7:30am Financial Instructional Course 

101 Cost-Effective and Tax-Efficient Managed 

Money for Physicians 

Physicians are busy individuals that require specialized 

services for their wealth management needs. This 

discussion will focus on managed money for 

physicians—the most cost-effective and tax-efficient 

way to manage money for high income earning 

individuals. We will discuss current investment 

opportunities and markets, maximizing the use of 

tax-free investments, as well as how to select the right 

investment consultants that specialize in managing 

money for healthcare professionals like you, who 

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 

7:30am – 8:30am Instructional Courses 

102 The Treatment of Basal Joint Arthritis: More 

than Just Trapeziectomy 

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 

options, beyond simple trapeziectomy, and emphasize 

pearls and pitfalls accompanying each. 

Matthew M. Tomaino, MD, Moderator 

Alejandro Badia, MD 

Randall W. Culp, MD 

Eduardo Zancolli. III, MD 

103 Treating Scapholunate Instability: A Gap 

Can Get You into Trouble 

This course will update the approach to treating this 

common and difficult carpal instability including 

surgical and therapy alternatives. 

Mel Rossenwasser, MD, Moderator 


104 Emerging Concepts in the Treatment of 

Common Tendonopathies 

This course offers practical pearls to patient management 

of the common tendonopathies from the 

elbow to the hand. 

Wyndell Merritt, MD, Moderator 

Julianne Howell, PT MS CHT 

Nash Naam, MD 

105 Solving the Failed Carpal/Cubital 

Tunnel Decompression 

This instructional course will address the challenging 

problem of evaluation and management of the 

patient with problems following failed carpal and 

cubital tunnel surgery. Key points in the physical 

examination and surgical technique of “redo 

“surgery will be emphasized. 

Susan Mackinnon, MD, Moderator 


Dean Sotereanos, MD 


106 Improving the Outcome of Flexor Tendon Repair 

This session will examine both traditional methods as 

well as focusing on new developments in flexor 

tendon repair, reconstruction, and rehabilitation with 

the goal of optimizing functional outcomes. 

Nicholas Vedder, MD, Moderator 

Peter Amadio, MD 



52 

107 I Read It In The Journal. Should I 

Change My Practice? 

How do we use principles of critical reasoning and evdence-based 

practice to make clinical decisions? Can 

you believe what you read in the journal? Those of us 

in clinical practice can be overwhelmed by the deluge of 

information on treatment options for a variety of hand 

and upper extremity conditions and overwhelmed by the 

literature. This panel will present methods to assist in 

treatment choices based upon contemporary peer 

reviewed literature. Join a hand surgeon, hand 

therapist, physical therapist/epidemiologist and statistician 

in a lively morning discussion. 

Susan Michlovitz, PT, PhD, CHT, Moderator 


Joy MacDermid, PhD, PT 

Paul Velleman, PhD 

8:30am – 8:40am President/Program Chair Welcome 

Ronald Palmer, MD, AAHS President 

A. Lee Osterman, MD, AAHS Program Chair 

Jorge L. Orbay, MD, AAHS Program Co-Chair 

Elvim Zook, MD, Editor of HAND 

8:40am – 8:45am ASSH Presidential Welcome 

David M. Lichtman, MD 

8:45am – 9:45am Throwing Darts on the Back Nine: 

What Every Hand Surgeon Should Know about 

Evolution and the Skilled Human Hand 

Hand surgeon Amy Ladd, anthropologist Mary Marzke, 

and neurologist Frank Wilson offer a Darwinian perspective 

on the management of complex hand disorders. 

Amy Ladd, MD 

Mary Marzke, Phd 

Frank Wilson, MD 

Mary Marzke, Phd, Professor of Anthropology at 

Arizona State University, received her AB (1959) and 

Ph.D. (1964) from the University of California Berkeley, 

and her M.A. from Columbia University (1961). Her 

research focuses on the evolution of the human hand 

and bipedality. 

Frank R. Wilson is retired clinical professor of neurology 

at Stanford University Medical Center, and a cofounder 

and former medical director of the Peter 

F. Ostwald Health Program for Performing Artists at the 

University of California School of Medicine, San 

Francisco. He is a graduate of Columbia College in New 

York City and the University of California School of 

Medicine in San Francisco and is the author of The Hand: 

How Its Use Shapes the Brain, Language, and Human 

Culture, nominated for a Pulitzer Prize for nonfiction 

in 1998. 

9:45am – 10:15am Wrist and Hand Joint Replacement: 

A Prosthetic Update 

Building on the lessons learned from the creative and 

forward thinking of the first endoprosthetic developers, 

today’s implants for the wrist and hand have seen 

significant improvements in design, longevity, durability 

and ease of implantation. This lecture will provide a 

overview of the “state of the art” of endoprosthetic 

treatment of wrist and hand arthritis with a historical 

perspective. 

Richard A. Berger, MD, PhD

10:15am – 10:25am Presentation of 2006 Vargas Trip to Romania 

Donna Pendleton, MS, PT, CHT 

Lorna Ramos, MA, OTR 

10:25am – 10:55pm Break with Exhibitors 

10:55am - 12:15pm CONCURRENT SCIENTIFIC 

PAPER SESSION 1A 

*Designates resident/fellow paper presentations 

Moderators: Brian Adams, MD 

Christine Novak, PT, MS 

10:55am - 11:00am 

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; Kimberlyamrami; Kai-Nan An, PhD 

11:00am - 11:05am 

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 

11:05am - 11:10am 

The Distal Radio Ulna Joint Prosthesis as an Effective Last Resort after Failed 

Salvage Procedure; a Study of Functional Outcomes in 18 Cases 

Institution where the work was prepared: cmki, louisville, KY, USA 

Adam Goodwin; luis laurentin 

11:10am - 11:15am 

*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, MD; Kazunari Tomita, MD; Richard A. Berger, MD, PhD 

11:15am - 11:20am 

Failed Darrach Procedure: an Allograft Solution 

Institution where the work was prepared: Allegheny General Hospital, Pittsburgh, 

PA, USA 

Filippos S. Giannoulis; Jeffrey A. Greenberg, MD; Rob W. Weiser, PA-C; Dean G. 

Sotereanos 

11:20am - 11:25am 

Discussion 

Moderators: Scott Kozin, MD 

Susan Michlovitz, PT, PhD, CHT 

11:25am - 11:30am 

*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, MD; Glenn Alan Teplitz, MD; Cory Oliver Nelson; Jonathon 

Devlin Botts; Yong Kwon; Frederick James Serra-Hsu 

11:30am - 11:35am 

*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 

11:35am - 11:40am 

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 

11:40am - 11:45am 

Discussion 

53 

11:45am - 11:50am 

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 

11:50am - 11:55am 

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; Lawrence Hurst, MD 

11:55am - 12:00pm 

Discussion 


PAPER SESSION 1B 


Moderators: Peter Amadio, MD 

Julianne Howell, PT, MS, CHT 

10:55am - 11:00am 

*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, MD; Eric T. Ricchetti; Miltiadis H. Zgonis; Heather L. Ansorge; 

Kenneth W. Liechty, MD; Louis J. Soslowsky, PhD; Pedro K. Beredjiklian, MD 

11:00am - 11:05am 

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 

11:05am - 11:10am 

*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 

11:10am - 11:15am 

*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 

11:15am - 11:20am 

Discussion 

11:20am - 11:25am 

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 

11:25am - 11:30am 

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 

11:30am - 11:35am 

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, MD; Donald S. Bae, MD; Peter M. Waters, MD

11:35am - 11:40am 

*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, MD; Gerald Sparkes; Amanda Higgins; Michael Neumeister; 

Donald H. Lalonde 

11:40am - 11:45am 

Discussion 

Moderators: Pedro Beredjiklian 

Aviva Wolff, BSC, OTR/L, CHT 

11:45am - 11:50am 

Single Incision Repair with Suture Anchors for Treatment of Distal Biceps 

Tendon Rupture: a 59 Cases Follow up 


PA, USA 

Filippos S. Giannoulis, MD; Rob W. Weiser; Dean G. Sotereanos 

11:50am - 11:55am 

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, CHT; James Gyovai, PT, CHT; Luis Vela, DO 

11:55am - 12:00pm 

*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, MD; Raymond K. Wurapa, MD; John M. Bednar, MD; Brent A. 

Bickel; Damon C. Adamany 

12:00pm - 12:05pm 

*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 

12:05pm - 12:10pm 

*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; E. Gene Deune, MD 

12:10pm - 12:15pm 

Discussion 

12:15pm – 1:00pm Keynote Speaker: Bob Jamieson 

Covering Medicine, Wars and Politics 

A Native of Illinois, Jamieson served in the U.S. Navy 

and attended Knox College from which he received 

an honorary doctor of letters degree in 1996. 

The address will focus on ABC's unique way of covering 

medicine, how we have been covering the 

middle east and the issues that will impact every day 

life in the United States as well as the political 

landscape that will affect us all. Questions will 

also be taken at the end of the address. 

Bob Jamieson joined ABC News in 1990 as a correspondent 

based in New York. During more than 30 

years as a network television news correspondent, 

Jamieson has reported from all seven continents, won 

five National News Emmys and was cited for his 

coverage of 9/11 as part of the ABC News team 

honored with both Alfred I. DuPont and George Foster 

Peabody Awards. His assignments with ABC News 

have varied widely, from the Kurdish refugee crisis in 

Northern Iraq after the first Gulf War to 9/11. 

54 

Jamieson has also reported extensively from the 

Middle East beginning with the 1973 Yom Kippur war 

and subsequently the 1982 conflict in Lebanon, from 

Iran, Syria, Jordan and Saudi Arabia and Baghdad. 

Beginning in 1971, he was assigned first as national 

correspondent in the Chicago bureau, then White 

House correspondent from 1975 to 1978, then to 

assignments in London and as a senior national 

correspondent based in New York. 

1:00pm – 1:30pm Lunch with Exhibitors 

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

1:30pm – 2:30pm Instructional Courses 

108 Advances In Extensor Tendon Repair And 

Rehabilitation: From Mallets To Motion 

This course will offer an up to date review of the 

current state of the art of extensor tendon repair and 

rehabilitation from the distal terminal tendon insertion 

to the proximal forearm. The participants will 

hear which injuries are best treated surgically, and 

which are best treated with splinting, casting or 

observation. 

John D. Lubahn, MD, Moderator 

Stephanie Sweet, MD 

109 Distal Radius Malunion: Prevention 

And Correction 

Malunion of the distal radius fracture is still one of the 

most common complications and one of the most 

common sources of legal action. These experts will 

address how to avoid the complication and, as 

importantly, how to restore radial anatomy. 

Jorge L. Orbay, MD, Moderator 

David Bozentka, MD 

110 Wide Awake Approach To Hand Surgery 

This course will provide the necessary information to 

allow the hand surgeon to perform most hand operations 

under pure local anesthesia without sedation and 

without a tourniquet. The wide awake pain free 

patient is able to actively move the reconstructed 

structures which the surgeon can observe and adjust 

before the skin is closed. The 4th dimension of active 

movement by the patient is added to the surgery. 

Donald H. Lalonde, MD, Moderator 


111 Reconstruction of the Burned Hand in Adults 

and Children 

Reconstruction of the burned hand in adults and 

children is presented through discussion and examples 

of acute and reconstructive principles. Planning 

reconstructive procedures requires thorough knowledge 

of scar contraction and burn maturation as well 

as surgical technique. This instructional course will 

provide insight into timing of surgical reconstruction 

and prognosis of return of maximum hand function. 

Roger Simpson, MD, Moderator 

Bruce Brewer, MD 

Anthony Smith, MD 

112 Surviving and Salvaging PIPJ Injuries 

This course will review the latest information on constrained 

and nonconstrained arthroplasty and on 

arthrodesis for irreparable PIPJ injuries and post 

traumatic arthritis. 

Alan Freeland, MD, Moderator 

Robert Beckenbaugh, MD 

Mark R. Belsky, MD 

113 Ulnar Wrist Pain: Understanding the Snaps, 

Clicks & Clunks 

This course will discuss the common causes of ulnar 

sided wrist pain, correlating the physical findings 

including snaps, clunks, and pops with the pathologic 

anatomy. The treatment for these common ulnar 

sided conditions will be discussed including splinting, 

non operative modalities and surgical solutions. 

John M. Bednar, MD, Moderator 

Scott G. Edwards, MD 

Mark Rekant, MD 

Teri Skirven, OTR/L, CHT 

2:40pm – 3:40pm Coding Alerts to Maximize the Work Unit Value 

The course will provide the insight into the RBRVS 

and coding updates, tips and pearls. 

Daniel Nagle, MD



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 


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 - 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 


10:55am - 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


Friday, January 12, 2007 

6:30am – 7:30am Financial Instructional Course 

for Non-Members 

114 Financial Planning for the Newly 

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 

important decisions you can make—one that can 

have an enormous impact on your long-term 

financial goals. This discussion will focus on 

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 

Jeff Palmer, Smith Barney Consulting Group 

7:00am – 7:30am Annual Business Meeting Breakfast 

(attendence is limited to AAHS members only) 


115 Resurrection of Dead Bone: Solving Kienboch’s 

and Avascular Non-Unions 

This instructional course will discuss the daignosis, 

classification and treatment options for scaphoid 

delayed union/nonunion with AVN, Preiser’s disease, 

Kienbock’s, as well as capitate AVN. Heavy emphasis 

will be placed on the newer armamentarium of VBG’s 

(vascularized bone graft) and their selective use for each 

of these difficult diagnostic categories. 

T. Greg Sommerkamp, MD, Moderator 

Kyle Bickel, MD, FACS 

Steven L. Moran, MD 

116 Pediatric Brachial Plexus Injury 

Discuss the management of pediatric brachial plexus 

injuries from diagnosis through treatment. Review 

operative indications for primary microsurgery and 

secondary reconstruction. Review surgical techniques, 

outcomes, and complications. 

Scott Kozin, MD, Moderator 

Allan J. Belzberg, MD 

Howard M. Clarke, MD 

117 Adult Elbow Fractures 

Elbow fractures are unforgiving. These experts will 

address the assessment, operative tactics, and complications 

associated with elbow fractures 

Mark Baratz, MD 

Michael R. Hausman, MD 

David Ring, MD 

118 New Concepts in Total Wrist Replacement 

This Instructional Course will provide updated 

information on new, precision guided replacement of 

the wrist. Presentations will include the current state 

of the art in Total Wrist Replacement with alternative 

procedures described along with initial results of 

treatment for both rheumatoid and posttraumatic 

arthritis of the wrist. 

William Cooney, III, MD, Moderator 


Luis Scheker, MD 

119 Innovations in Scaphoid Care 

The faculty will review their reconstructive approach 

to mutilating hand injuries, including general 

princibles, timing and latest techniques in skeletal and 

soft tissue reconstructions. 

Alexander Shin, MD 

Joseph Slade, III, MD 

120 Post Traumatic Hand Reconstruction 

The faculty will review their reconstructive approach 

to mutilating hand injuries, including general 

principles, timing and latest techniques in skeletal 

and soft tissue reconstructions. 

W.P. Andrew Lee, MD, Moderator 

Richard E. Brown, MD 

Alexandru Georgescu, MD 


56 

8:35am – 9:20am Panel: Problem Solving in Distal Radius 

Fracture 

Jaiyoung Ryu, MD Moderator 


Amy Ladd, MD 


9:00am – 11:00am ASRM Strategic Planning Session 

9:20am – 9:50am Presidential Address 


9:50am – 10:25am J. Joseph Danyo Presidential Invited Lecturer: 

Robert D. Beckenbaugh, MD 


“Is It Fun Anymore?” 

Medical practice has changed drastically over the last 

thirty years. We have seen conversion of patient 

oriented caring medical treatment to business 

oriented money making, cost saving approaches to 

patient care. Questions arise with regard to the ethics 

and morality of such changes. Is there room to 

provide expert care and have fun as a physician 

anymore in caring for the, injured, ill or especially the 

profitless elderly? The answer may lie in our original 

reasons for going into medicine and the oath which 

we have all taken. 

Robert Beckenbaugh, MD is Professor of Orthopedic 

Surgery at the Mayo Clinic Rochester. His research 

interests include continuing work on the development 

of artificial joint replacements for the wrist and 

hand. He served as president of the AAHS from 1992-3. 


PAPER SESSION 2A 


Moderators: Kevin Chung, MD 


10:55am - 11:00am 

The Cause of Carpal Tunnel Syndrome? 

Institution where the work was prepared: University of Louisville, School of Public 

Health and Informatio, Louisville, KY, USA 

Steven J. McCabe, MD, MSc; Vasyl Pihur; Roberto S. Rosales, MD, PhD; Isam 

Atroshi, MD, PhD 

11:00am - 11:05am 

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; Kris Robinson, PhD, FNP 

11:05am - 11:10am 

*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 

11:10am - 11:15am 

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 

11:15am - 11:20am 

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

11:20am - 11:25am 

Discussion 

Moderators: Keith Brandt, MD 


11:30am - 11:35am 

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 

11:35am - 11:40am 

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, CHT; Ann E. Barr, DPT, PhD; Mamtaamin; Marcus J. 

Handy; Mary F. Barbe, PhD 

11:40am - 11:45am 

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 

11:45am - 11:50am 

Peripheral Nerve Injuries and Nerve grafting 

Institution where the work was prepared: Boston University School of Medicine, 

Boston, MA, USA 

Harilaos Theodore Sakellarides, MD 

11:50am - 11:55am 

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 

11:55am - 12:00pm 

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 

12:00pm - 12:05pm 

Discussion 

Moderators: Allen van Beek, MD 

Nick Vedder, MD 

12:05pm - 12:10pm 

*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 

12:10pm - 12:15pm 

Traumatic Thumb Reconstruction by Index Pollicization 


Cesar J. Bravo, MD; Alexander Shin, MD; Allen T. Bishop, MD; Steven Moran 

12:15pm - 12:20pm 

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 

12:20pm - 12:25pm 

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 

57 

12:25pm - 12:30pm 

Discussion 


PAPER SESSION 2B 


10:55am - 11:30pm 

Moderators: Peter Murray, MD 

Nash Naam, MD 

10:55am - 11:00am 

*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 

11:00am - 11:05am 

LRTI Carpometacarpal Joint Arthroplasty With Flexor Carpi Radialis Sparing 

Allograft: A Review of 30 Cases 


PA, USA 

Dean G. Sotereanos; Filippos S. Giannoulis; Rob W. Weiser 

11:05am - 11:10am 

Arthroscopic Cuetis Interpositional Arthroplastyof The BasilarJointof The Thumb 

Institution where the work was prepared: Kaiser Permanente, Bakersfield, CA, USA 

Albert R. Swafford, MD 

11:10am - 11:15am 

Long Term Outcome of Thumb Trapeziometacarpal Arthrodesis: A Review of 

178 Cases 


Marco Rizzo, MD; Steven L. Moran, MD; Alexander Y. Shin 

11:15am - 11:20am 

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 

11:20am - 11:25am 

Discussion 

Moderators: Kevin Plancher, MD 

Dean Soteareanos, MD 

11:25am - 11:30am 

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 

11:30am - 11:35am 

Nerve Ending Distribution in Human Radiocarpal Ligaments: a Fluorescent 

Immunohistochemical Study 


Kazunari Tomita, MD; Richard A. Berger, MD, PhD; Evelyn Berger; Kai-Nan An, 

PhD; Jirachart Kraisarin, MD 

11:35am - 11:40am 

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, PhD; Miriam Müller, MD; Günter Germann, MD, PhD 

11:40am - 11:45am 

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, PhD; Hiroyasu Ikegami; Kazuki Sato; Noriaki 

Nakamichi; Noriko Okuyama; Shinichiro Takayama, MD, PhD

11:45am - 11:50am 

*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 

11:50am - 11:55am 

Discussion 

Moderators: Richard E Brown, MD 

Dan Nagle, MD 

12:00pm - 12:05pm 

*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 

12:05pm - 12:10pm 

*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 

12:10pm - 12:15pm 

*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, MD; Peter J.L. Jebson; Peter M. Murray, MD; Stephen D. Trigg, 

MD 

12:15pm - 12:20pm 

*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 

12:20pm - 12:25pm 

Discussion 

11:00am – 1:00pm ASRM Council Meeting 

12:30pm – 1:00pm Hand Federacion Presentation: 

Contributions and Influences of Argentina 

to Hand Surgery 

History of Hand Surgery in Argentina beginning in 

the early 50´s and presenting all the main contributions 

of Argentinian surgeons helping the 

knowledge of our speciality. 

Eduardo Zancolli III, MD 

1:00pm – 6:15pm Comprehensive Hand Surgery Review Course 

Peter M. Murray, MD, Chairman 

Randy Bindra, MD, Co-Chairman 

The excellent faculty of this Comprehensive Hand 

Surgery Review Course will address the important 

topics covered on board examinations, the hand 

surgery certification examination and resident 

in-training examinations. From arthrogryposis to 

Z-plasty, this course will truly have it all and you 

will consider it time well spent. 

Course is complimentary, but pre-registration is required. 

Box lunch will be provided. 

1:00pm – 1:15pm Tendonopathies and Dupuytrens Contracture 

Tendonopathies of the hand and wrist and 

Dupuytrens Contracture are among the most 

common problems seen in hand surgery. An 

overview of the pathophysiology of these 

conditions will be provided as well as specific 

treatment recommendations. 

Peter M. Murray, MD 

58 

1:15pm – 1:35pm Compressive Neuropathies & CRPS 

In this lecture carpal tunnel syndrome and cubital 

tunnel syndrome will be reviewed. Physical examination 

and diagnostic modalities will be emphasized. 

The last portion of the presentation will review the 

diagnosis, treatment and long-term sequelae of 

complex regional pain syndrome. 

Daniel Nagle, MD 

1:35pm – 2:00pm Thumb Basal Joint Arthritis, Wrist Arthritis, 

Kienbock’s Disease 

This lecture will address the fundamentals of diagnosis 

and treatment for thumb basal joint arthritis, 

SLAC/SNAC degeneration of the wrist, and avascular 

necrosis of the lunate. Critical success factors 

necessary to obtain favorable outcomes will be 

emphasized. 

Matthew Tomaino, MD 

2:00pm – 2:25pm Inflammatory Arthritis of the Hand and Wrist 

Reconstructive options for deformities secondary to 

rheumatoid arthritis and other inflammatory conditions 

will be outlined. Indications and techniques for 

MCP arthroplastied, tendon reconstruction, synovectomy, 

wrist arthrodesis and total wrist arthroplasty 

with be reviewed. 


2:25pm – 2:45pm Distal Radius Fractures 

A comprehensive review of adult distal radius fractures 

including the clinical evaluation, diagnostic 

imaging options and interpretation, indications for 

operative versus non-operative treatment and the 

current strategies and indications for the various 

operative treatment techniques. 

Peter J. L. Jebson, MD 

2:45pm – 2:55pm Distal Radioulnar Joint 

Anatomy, biomechanics and patterns of injury will be 

discussed. Bone and soft tissue salvage reconstructive 

options will be illustrated. 


2:55pm – 3:10pm Scaphoid Fractures and Non-Unions 

A review of the clinical features, diagnostic challenges, 

operative and non-operative treatment 

options, and a contemporary approach to the patient 

with an acute scaphoid fracture or established 

non-union. 

Peter J. L. Jebson, MD 

3:10pm – 3:30pm Carpal Instability 

A review of the anatomy and mechanics of the wrist 

as it relates to carpal instability, including a review of 

the diagnostics and treatment of common patterns 

of instability. 


3:30pm – 3:45pm Fractures of the Metacarpals and Phalanges 

Metacarpal and phalangeal fractures are among the 

most common injuries seen in the hand. A thorough 

review of the anatomy and biomechanics of these 

injuries will be provided. The treatment choices of 

closed management, percutaneous pinning, plate 

fixation and intramedullary rodding will be reviewed 

along with their technical nuances. 

Stephen D. Trigg, MD 

3:45pm – 4:00pm Flexor & Extensor Tendon Injuries 

This presentation will review aspects of physical exam 

and radiographic analysis of extension tendon injuries, 

technical aspects and biomechanical data and post op 

rehab protocols. Basic science of tendon healing and 

repair will also be discussed. 

Kevin J. Renfree, MD 

4:15pm – 4:30pm Infections of the Hand 

Comprehensive review of infections of the hand with up to 

date information to allow the participant to feel comfortable 

treating patients with their maladies and being able to 

successfully complete their questions on the Certificate of 

Added Qualifications exam. 

Kevin D. Plancher, MD, MS, FACS, FAAOS

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, radiology 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. 


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. 


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 reimplantation 

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 groundbreaking 

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 


59

AAHS/ASRM/ASPN 


Saturday, January 13, 2007 


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


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

AAHS/ASRM/ASPN 


6:30am – 7:30am Continental Breakfast 

7:00am – 8:00am Panel: Upper Extremity Injuries in 

Modern Warfare 

This symposium given by members of the active 

military will detail the advances in the treatment of 

upper extremity war injury from the battlefield 

through reconstruction and prosthetics. 

CDR Erik Hofmeister, MD 

CDR Michael A. Thompson, MD 

CDR Michael T. Mazurek, MD 

8:00am – 8:10am AAHS/ASRM/ASPN Presidents Welcome 

Ronald Palmer, MD, AAHS President 

L. Scott Levin, MD, FACS, ASRM President 

Rajiv Midha, MD, ASPN President 

ASPS Presidential Remarks 

8:10am – 9:10am AAHS/ASRM/ASPN Presidents Invited Lecture: 

Richard H. Gelberman, MD 

Identifying Targets for Clinical and Research 

Excellence in 2007 

The purpose of this presentation is to present a 

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 

Professor and Chairman of the Department of 

Orthopaedic Surgery at the Washington University 

School of Medicine and Chairman of Orthopaedic 

Surgery at Barnes-Jewish Hospital in St. Louis, 

Missouri. 


9:30am - 10:30am OUTSTANDING NERVE PAPER PRESENTATIONS 



Moderator: A. Lee Osterman, MD 


9:30am - 9:38am 

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 

9:38am - 9:40am 

Discussion 

9:40am - 9:48am 

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 

61 

9:48am - 9:50am 

Discussion 


Moderator: Robert J. Spinner, MD 

9:50am - 9:58am 

*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, MD; Gerard J Boer; Joost Verhaagen; Martijn J.A. Malessy 

9:58am - 10:00am 

Discussion 

10:00am - 10:08am 

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, MD; Kuang-Te Chen, MD; David CC Chuang; Yu-Te 

Lin, MD; Paul Tulley, MD 

10:08am - 10:10am 

Discussion 


Moderator: Michael Zenn, 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, 

Taipei, Taiwan 

Yueh-Bih Chen Tang, MD, Ph, D; Hui-Hsiu Chang, resident; Hung-Chi Chen, MD, 

FACS 

10:15am – 10:18am 

Discussion 

10:18am – 10:26am 

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 

10:26am – 10:30am 

Discussion 

10:30am – 11:30am Panel: Brachial Plexus Surgery 2007 

This panel will discuss the current status of phrenic nerve 

transfer and of the CNS/PNS interface as well as other new 

nerve transfers. In addition, the panel will talk about the 

management of a patient with an upper pattern injury 

present in six months after injury and the management of 

a patient with a complete brachial plexus lesion 

presenting 3 months after injury. 

Allan Belzberg, MD, Moderator 

Robert J. Spinner, MD, Moderator 

Prof. Rolfe Birch 


Jianguang Xu, MD, PhD, MBA 

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

See page 16 for details

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 


Maurice Nahabedian, MD, FACS 

1:50pm – 2:15pm Superior Gluteal Artery Perforator (SGAP) Flap 

Bernard Chang, MD, FACS 


Robert J. Allen, MD 

2:25pm – 2:40pm Break 

2:40pm – 3:05pm Vascularized Epiphyseal Transfer 

Marco Innocenti, MD 



3:15pm – 3:40pm Esophageal Reconstruction 

Hung-Chi Chen, MD 


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





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



1:00pm – 2:00pm Invited Speaker: Prof. Xavier Navarro 

Acebes, MD, PhD 

Prof. Xavier Navarro Acebes, MD, PhD, Dept. Cell 

Biology, Physiology and Immunology, Institute of 

Neurosciences, Universitat Autonoma de Barcelona, 

Bellaterra, Spain 

Tube Repair: Advances towards an Artificial 

Nerve Graft 

Tube repair has emerged as an effective alternative to 

direct suture or short grafts for repairing severed 

peripheral nerves. However, simple tubes have a limit 

to regeneration depending upon the length of the 

gap. The characteristics of the guide wall, in terms of 

permeability, durability and adhesiveness, also influence 

regeneration. Taking into account the importance 

of the cellular component in regeneration, the 

development of an artificial graft, composed of a 

biocompatible nerve guide filled with a neurotropic 

matrix and seeded with Schwann cells, is a reasonable 

option to enhance nerve regeneration and to 

become an alternative to long autologous nerve 

grafting. Over the past years several of the techniques 

required to develop a transplantation program using 

Schwann cells prepared in culture have been achieved. 

However, the origin and the density of transplanted 

cells determine the outcome. Coadjuvant treatment 

with FK506 allows for enhanced regeneration and 

also for preventing rejection of heterologous 

Schwann cell transplants. 

2:00pm - 3:30pm SCIENTIFIC PAPER 

PRESENTATIONS SESSION A 


Moderators: Howard M. Clarke, MD, PhD 

Allan J. Belzberg, MD 

2:00pm - 2:06pm 

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 

2:06pm - 2:08pm 

Discussion 

2:08pm - 2:14pm 

*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 

2:14pm - 2:16pm 

Discussion 

2:16pm - 2:22pm 

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 

2:22pm - 2:24pm 

Discussion 

Sponsored by: 

2:24pm - 2:30pm 

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 

64 

2:30pm - 2:32pm 

Discussion 

2:32pm - 2:34pm 

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 

2:34pm - 2:35pm 

Discussion 

2:35pm - 2:39pm 

*Metastatic Breast Cancer Recurrence to the Brachial Plexus - MRI Imaging 

Characteristics 


Helena Gerhardt Summers, MD; Kimberly Amrami; Robert Spinner, MD 

2:39pm - 2:41pm 

Discussion 

2:41pm - 2:43pm 

Outcome Measures in Brachial Plexus Reconstruction 


Keith A. Bengtson, MD; Brian Kotajarvi, PT; Allen Bishop, MD; Robert Spinner, MD; 


2:43pm - 2:44pm 

Discussion 

Moderators: Martijn J. A. Malessy, PhD 

Gedge Rosson, MD 

2:44pm - 2:48pm 

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 

2:48pm - 2:50pm 

Discussion 

2:50pm - 2:54pm 

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 

2:54pm - 2:56pm 

Discussion 

2:56pm - 3:00pm 

Atraumatic Electrophysiologic Evaluation of Nerve Regeneration Following 

Nerve Injuries of the Forelimb in Rats 


Huan Wang, MD, PhD; Eric J. Sorenson, MD; Anthony J. Windebank, MD; Robert 

J. Spinner, MD 

3:00pm - 3:02pm 

Discussion 

3:02pm - 3:06pm 

Development of Assessment Tasks for Evaluating Deficits and Recovery of 

Forelimb Function following Nerve Lesions in Rats 


Huan Wang, MD, PhD; Eric J. Sorenson, MD; John P. Bois, BA; Godard C.W. De 

Ruiter, MD; Anthony J. Windebank, MD; Robert J. Spinner, MD 

3:06pm - 3:08pm 

Discussion

3:08pm - 3:12pm 

*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 

3:12pm - 3:14pm 

Discussion 

3:14pm - 3:18pm 

*Accuracy of Motor Axon Regeneration After Different Types of Nerve Injury 

and Repair in the Rat Sciatic Nerve Model 


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, 

MD 

3:18pm - 3:20pm 

Discussion 

3:20pm - 3:24pm 

*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, MD; Max Haerle, MD; Stefan Becker, MD; Burkhard Schlosshauer, 

PhD; Michael Doser, PhD; Harald Roesner, PhD; Klaus Dietz, MD; Hans-Werner 

Mueller, PhD; Hans-Eberhard Schaller, MD 

3:24pm - 3:26pm 

Discussion 

3:26pm - 3:28pm 

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, Drs; J.F.C. Wolfs; Ana P. Pego, Drs; R.J. van 

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 

challenges in C7 transfer, especially the difficulty in 

achieving independent movement, are discussed. 

Preliminary results of studies on brain plasticity following 

contralateral C7 transfer will be reported. Other 

indications of C7 transfer, e.g. repair of Bell’s palsy, 

accessory nerve injury, and paraplegia, will also be 

discussed. 

4:30pm – 5:00pm Invited Speaker: Prof. Rolfe Birch 

Prof. Rolfe Birch, Peripheral Nerve Injury Unit, Royal 

National Orthopaedic Hospital, Stanmore, Middlesex, 

United Kingdom 

Iatropathic Injuries of Peripheral Nerves 

Incidence in the United Kingdom. A growing problem: 

defects in teaching; defects in training. Reasons for 

delay in recognition and in treatment: error in 

diagnosis; failure to understand functional significance 

of the peripheral nervous system; failure to recognize 

the place of operation for diagnosis, for repair, for 

palliation. 

The spinal accessory nerve: delay in diagnosis; 

functional consequences; the significance of neuropathic 

pain. The problem of the nerves of cutaneous 

sensation: the particular vulnerability of the medial 

cutaneous nerve of forearm, the superficial radial nerve 

and the sural and the saphenous nerve. Injury to major 

nerves at the hip: predisposing factors; onset; expression 

of neuropathic pain; depth of lesion; the indications for, 

and results of second operation. Hazards of interscalene 

and other brachial plexus local blocks. The formation of 

the anterior spinal artery; the contribution of radicular 

vessels; their vulnerability to tamponade. The 

innervation of the shoulder joint. Recommendation 

towards reduction of incidence of iatropathic lesion and 

towards improvement in treatment. 

6:30pm – 8:00pm ASPN Welcome Reception 


Sponsored by:



Sunday, January 14, 2007 




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




7:00am – 8:15am ASPN Instructional Courses 

201 Brachial Plexus Birth Palsy 

Birth Related Brachial Plexus Injury (BRBPI) remains 

a controversial topic in terms of etiology, prevention, 

and management. For example, early versus 

delayed nerve surgery is hotly debated. We will 

explore various aspects of this injury using case 

based education. 




202 Cortical Reorganization 

Cortical plasticity follows peripheral nerve injury, 

regeneration and rehabilitation. 

Dimitri Anastakis, MD 

Martijn Malessy, MD 

203 Reinnervating Muscle 

Motoneurons can reinnervate as many as 5 times as 

many muscle fibers after injury and nerve repair as 

they normally do. This enlargement of the reinnervated 

motor unit size compensates for reduced 

numbers of motor nerves that succeed in regenerating 

to reinnervate the denervated muscles. We 

will consider this issue of enlarged reinnervated 

motor units in the context of whether regeneration 

of a smaller component of the normal number of 

nerves to a muscle is sufficient to restore 

muscle function, even should the nerves regenerate 

back to their original target muscles. We will also 

consider the question of whether type grouping of 

muscle fibers after muscle denervation and 

reinnervation and whether or not this type grouping 

is a sufficient basis for diagnosis of muscle 

denervation and reinnervation. 



204 Peripheral Nerve Tumors 

This instructional course will cover the evaluation 

and management of benign and malignant 

peripheral nerve tumors. 

Ab Guha, MD 



205 Intraoperative Monitoring 

Course attendees will learn how intraoperative 

nerve action potentials, somatosensory evoked 

potentials and motor nerve studies facilitate 

intraoperative decision making during surgery for 

peripheral nerve lesions. The role of pre-operative 

electromyography and nerve conduction 

studies as they relate to the intraoperative studies 

will also be described. 

David Houlden, MD 

Robert Tiel, MD 


67 

8:30am – 9:30am ASRM/ASPN Panel: Functioning 

Muscle Transfer 

Allen T. Bishop, MD, Moderator 

David Chwei-Chin Chuang, MD 




9:50am – 10:00am Welcome Remarks 

Rajiv Midha, MD, ASPN President 

Robert Spinner, MD, ASPN Program Chair 

10:00am - 11:30am SCIENTIFIC PAPER 

PRESENTATIONS SESSION B 


Moderators: Ivica Ducic, MD, PhD 

Marcel Meek, MD, PhD 

10:00am - 10:02am 

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 

10:02am - 10:03am 

Discussion 

10:03am - 10:05am 

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 

10:05am - 10:06am 

Discussion 

10:06am - 10:08am 

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 

10:08am - 10:09am 

Discussion 

10:09am - 10:13am 

*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 

10:13am - 10:15am 

Discussion 

10:15am - 10:19am 

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

10:19am - 10:21am 

Discussion 

10:21am - 10:23am 

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 

10:23am - 10:24am 

Discussion 

10:24am - 10:28am 

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 

10:28am - 10:30am 

Discussion 

Moderators: Jonathan M. Winograd, MD 


10:30am - 10:35am 

*The Cystic Transverse Limb of the Articular Branch: A Pathognomonic Sign 

for Peroneal Intraneural Ganglion Cysts at the Superior Tibiofibular Joint 


Nicholas M. Desy, BSc; Kimberly K.amrami, MD; Robert J. Spinner, MD 

10:35am - 10:37am 

Discussion 

10:37am - 10:41am 

*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, Dr; Iordanis Mourouzis; Kostas Mourouzis; Constantinos 

Pantos; Nikolaos Gerostathopoulos; Dimitrios Ntallas, Dr; George Macheras, Dr; 

Efstathios Boviatsis, Dr 

10:41am - 10:43am 

Discussion 

10:43am - 10:47am 

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 

10:47am - 10:49am 

Discussion 

10:49am - 10:53am 

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, PhD; Bernadeta Michalski; James Bain, MD, MSc 

10:53am - 10:55am 

Discussion 

10:55am - 10:59am 

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 

68 

10:59am - 11:01am 

Discussion 

11:01am - 11:05am 

*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 

11:05am - 11:07am 

Discussion 

11:07am - 11:13am 

*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 

11:13am - 11:15am 

Discussion 

11:15am - 11:19am 

*Induction of Regional Collateral Sprouting Following Muscle Denervation 



Arash Moradzadeh, MD; JW Koob, BA; Alice Tong; Ayato Hayashi, MD; Terence 

M. Myckatyn, MD; Thomas H. Tung, MD; Susan E. Mackinnon, MD 

11:19am - 11:21am 

Discussion 

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

1:00pm – 2:00pm Invited Speaker: Tessa Gordon, PhD 

Sponsored by: 

Tessa Gordon, PhD. Center for Neuroscience, Division of 

Physical Therapy and Rehabilitation, Faculty of Medicine, 

University of Alberta, Edmonton, Alberta 

Emerging Strategies to Improve Outcome 

of Nerve Injury 

Despite the capacity for injured peripheral nerves to 

regenerate their axons, functional outcome may be poor, 

especially for injuries that require axon regeneration over 

considerable distances. We established that the long 

durations that neurons remain chronically axotomized prior 

to target reinnervation and the chronic denervation 

of the Schwann cells in the distal nerve stumps, severely 

curtail the success of axon regeneration, and in turn, functional 

recovery. I will review our data demonstrating the 

effectiveness of exogenous neurotrophic factors in sustaining 

the regenerative capacity of chronically axotomized 

motoneurons and a strategy of using cytokines to 

reactivate Schwann cells, to promote their proliferation, and 

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 

surgical suture site. I will describe experiments in which we 

demonstrate that a very long period of 4 weeks is required 

for all neurons to regenerate their axons across the surgical 

junction between proximal and distal nerve stumps in rats, 

the reported latent period of days corresponding only to a 

small proportion of the axons that cross the lesion site 

within the time period. We found that low frequency 

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 

the motor and sensory neurons. I will communicate our 

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 

tunnel release surgery promoted axon regeneration such 

that the number of reinnervated motor units in the thenar 

muscles of the patient group of stimulation increased to 

normal levels within 6-8 months as compared to a trend for 

unstimulated median nerves to regenerate but 

for the motor unit numbers not to approach normal levels 

within 1 year of surgery. This significant increase found in

the numbers of reinnervated motor units with electrical 

stimulation was accompanied by increased manual 

dexterity (Purdue Pegboard test), reduced symptom 

severity (Levine symptom severity questionnaire), and 

improved skin sensation (Semmes-Weinstein monofilaments). 

These data indicate that electrical stimulation at 

the time of surgical repair is a feasible strategy to promote 

axonal regeneration in humans and that it has the 

potential to improve functional outcomes after surgical 

repair of injured peripheral nerves. This strategy opens 

opportunities to enhance axon regeneration after 

peripheral nerve injury by combining with brief electrical 

stimulation to promote axon out-growth across the 

suture site with strategies to sustain both the regenerative 

capacity of the axotomized neurons and Schwann cell 

support of the regenerating axons over distance and time. 

(I wish to thank the CIHR of Canada for their financial 

support of this work). 

2:00pm - 4:00pm SCIENTIFIC PAPER 

PRESENTATIONS SESSION C 


Moderators: Paul S. Cederna, MD 


2:00pm - 2:04pm 

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, MD; Susan Mackinnon; James T. Heaton, PhD 

2:04pm - 2:06pm 

Discussion 

2:06pm - 2:10pm 

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, MD; Tsu-Hsiang Lu, BA; Seng -Feng Jeng, MD; Shun-Sheng 

Chen, MD, PhD 

2:10pm - 2:12pm 

Discussion 

2:12pm - 2:16pm 

Harvested Human Neurons Engineered as Live Nervous Tissue Constructs: 

Implications for Transplantation 


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 

2:16pm - 2:18pm 

Discussion 

2:18pm - 2:24pm 

*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. Ma; J.C.V.M. Copray; G.M. van Dam; H.W.G.M. Boddeke; M.F. Meek, MD, PhD 

2:24pm - 2:26pm 

Discussion 

2:26pm - 2:30pm 

*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 

2:30pm - 2:32pm 

Discussion 

69 

2:32pm - 2:38pm 

*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, BSc; J. Biernaskie; F. Miller; Raj Midha, MD, MSc 

2:38pm - 2:40pm 

Discussion 

2:40pm - 2:44pm 

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 

2:44pm - 2:46pm 

Discussion 

2:46pm - 2:50pm 

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; Ronald Schnaar, PhD 

2:50pm - 2:52pm 

Discussion 

2:52pm - 2:56pm 

*Effects of Motor Versus Sensory Nerve Architecture on Regeneration Through 

Cold Preserved Nerve Grafts 



Arash Moradzadeh, MD; Christopher M. Nichols, MD; Jason W. Koob, BA; Daniel 

A. Hunter, RA; Susan E. Mackinnon, MD 

2:56pm - 2:58pm 

Discussion 

2:58pm - 3:02pm 

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 

3:02pm - 3:04pm 

Discussion 

Moderators: A. Lee Dellon, MD 


3:04pm - 3:10pm 

*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 

3:10pm - 3:12pm 

Discussion 

3:12pm - 3:16pm 

*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

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 


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 


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







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 


9:50am - 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




7:00am – 2:00pm Patient Safety Computerized Presentations 

Computerized patient safety modules will be 

available throughout the meeting for individual use 

(1 CME hour each). In addition to the CME received 

for meeting attendance, these modules will allow 

attendees to increase the designated patient safety 

CME received. 

7:00am – 7:15am Welcome 

L. Scott Levin, MD, FACS, ASRM President 

Michael Zenn, MD, ASRM Program Chair 


PRESENTATIONS SESSION A-1 


Moderators: Elisabeth Beahm, MD 


7:15am – 7:18am 

*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 

7:18am – 7:21am 

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 Paul University Hospital, Bracelona, Spain 

Jaume Masia, MD, PhD; J. A. Clavero, MD 

7:21am – 7:25am 

Discussion 

7:25am – 7:28am 

*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, 


Constance M. Chen, MD, MPH; Eric Halvorson; Joseph J. Disa; Babak J. Mehrara; 

Andrea L. Pusic; Peter G. Cordeiro 

7:28am – 7:31am 

*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 

7:31am – 7:34am 

*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 

7:34am – 7:40am 

Discussion 

72 

7:40am – 7:43am 

Timing and Predictors of Arterial and Venous Thrombosis Following 

Autologous Free TRAM Breast Reconstruction 


TX, USA 

Michel Saint-Cyr, MD; David W. Chang, MD 

7:43am – 7:46am 

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 

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? 


PA, USA 

Jesse Creed Selber, MD, MPH; Stephen J. Vega, MD; Seema Sonnad; Joseph 

Serletti 

7:49am – 7:55am 

Discussion 

7:55am – 7:58am 

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 

7:58am – 8:01am 

*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 

8:01am – 8:04am 

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 

8:04am – 8:10am 

Discussion 

8:10am – 8:13am 

The Sensational Breast Reconstruction: Innervated versus Non-Innervated 

Flaps 

Institution where the work was prepared: The Methodist Hospital, Houston, TX, 

USA 

Aldona J. Spiegel, MD; Farah Naz Khan, MD; Michael Charles Edwards, MD/PhD; 

Joe P. Day, PhD 

8:13am – 8:16am 

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, MD; Darrell Brooks, MD; Karen M. Horton, MD, MSc 

8:16am – 8:19am 

*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 

8:19am – 8:30am 

Discussion

7:15am – 8:30am SCIENTIFIC PAPER 

PRESENTATIONS SESSION A-2 


Moderators: Gunter Germann, MD 

Gabriel Kind, MD 

7:15am – 7:18am 

Replantation in Developing Countries 

Institution where the work was prepared: SOS Mano Santo Domimngo, Hand 

group, Santo Domimngo, Dominican Republic 

Hector Herrand, MD; Marcos Nuñez, MD; Otoniel Diaz, MD 

7:18am – 7:21am 

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 

7:21am – 7:24am 

*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 

7:24am – 7:30am 

Discussion 

7:30am – 7:33am 

*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 

7:33am – 7:36am 

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 

7:36am – 7:39am 

*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 

7:39am – 7:45am 

Discussion 

7:45am – 7:48am 

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, MD; Aharonamir; David Leshem; Yoav Barnea; Jerry Weiss; Yehuda 

Kollender, MD; Jacob Bickels; Izzac Meller; Eyal Gur 

7:48am - 7:51am 

*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 

7:51am – 7:54am 

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 

73 

7:54am – 8:00am 

Discussion 

8:00am – 8:03am 

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 

8:03am – 8:06am 

*Arterial Reconstruction for Ulnar Artery Thrombosis 



G.D. Chloros, MD; Robert M. Lucas; Martha Holden; L. Andrew Koman 

8:06am – 8:09am 

*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, MD; Keith E. Follmar; Giorgio De Santis, Professor; Roberto 

Adani; Massimo Pinelli; Marco Innocenti, MD; Steffen P. Baumeister; Henning von 

Gregory; Günter Germann; Detlev Erdmann; L. Scott Levin 

8:09am – 8:15am 

Discussion 

8:15am – 8:18am 

Free Flap Reconstruction Extends the Indications for Forequarteramputation 

Institution where the work was prepared: Helsinki University Hospital, Helsinki, 

Finland 

Erkki Tukiainen; Outi Kaarela, MD, PhD 

8:18am – 8:21am 

*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 

8:21am – 8:24am 

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. 

8:24am – 8:30am 

Discussion 

8:30am – 9:30am ASRM/ASPN Panel: Functioning Muscle Transfer 

Allen T. Bishop, MD, Moderator 






PRESENTATIONS SESSION B-1 


Moderators: Mustafa Akyurek, MD 

Joseph Disa, MD 

9:50am – 9:53am 

Functional Reconstruction of Complex Lip Defect with One Free Composite 

Anterolateral Thigh Fascia-Cutaneous Flap 



Yur-Ren Kuo; Seng-Feng Jeng; Jir-Wen Yin, MD; Ching-Hua Hsien 

9:53am – 9:56am 

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

9:56am – 10:00am 

Discussion 

10:00am – 10:03am 

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, FR; Christine B. Novak, PT, MS, PhD(c); Peter 

C. Neligan, MB, FRCSC, FACS 

10:03am – 10:06am 

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, 


Jason Spector, MD; Pierre Saadeh; Stephen M Warren; Sunil P Singh; Pierre 

Boutros Saadeh; Joseph G McCarthy; John W Siebert 

10:06am – 10:10am 

Discussion 

10:10am – 10:13am 

*Safety and Reliability of the Ulnar Artery Perforator Flap 

Institution where the work was prepared: R Adams Cowley Shock Trauma Center, 


Suhail K. Mithani, MD; Rachel Bluebond-Langner, MD; Gedge D. Rosson, MD; 

Eduardo D. Rodriguez, DDS, MD 

10:13am – 10:16am 

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 

10:16am – 10:20am 

Discussion 

10:20am - 10:23am 

*The Alliance of Craniofacial and Microsurgery in Composite Mid-Face 

Reconstruction: Introduction of the Girder System Using the Free Fibula 

Osteoseptocutaneous Flap 



Julie E. Park, MD; Rachel Bluebond-Langner, MD; Paul N. Manson, MD; Eduardo 

D. Rodriguez, DDS, MD 

10:23am – 10:26am 

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 

10:26am – 10:30am 

Discussion 


PRESENTATIONS SESSION B-2 


Moderators: Raymond Dunn, MD 

Detlev Erdmann, MD 

9:50am – 9:53am 

*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 

74 

9:53am – 9:56am 

*Fasciocutaneous versus Muscle Flaps Following Lower Extremity Trauma: A 

Pilot Study of Functional Outcomes 



Rachel Bluebond-Langner, MD; Navin K. Singh, MD; Gedge D. Rosson, MD; Suhail 

Mithani; Eduardo D. Rodriguez, DDS, MD 

9:56am – 10:00am 

Discussion 

10:00am – 10:03am 

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 

10:03am – 10:06am 

*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, 


Christine Rohde, MD; Matthew R. Greives; Curtis L. Cetrulo Jr, MD; Oren Z. 

Lerman, MD; Alexes Hazen, MD; Jamie P. Levine, MD 

10:06am – 10:10am 

Discussion 

10:10am – 10:13am 

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 

10:13am – 10:16am 

*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, MD; Charles K. Lee; Gil S. Kryger, MD; Gregory M. Buncke 

10:16am – 10:20am 

Discussion 

10:20am – 10:23am 

*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, MD; John P. Dormans, MD; David W. Low, MD; Benjamin 

Chang, MD 

10:23am – 10:26am 

*A long-Term Study Of Donor Site With A Split Fibula Bone Graft After 

Vascularized Fibula Flap Transfer In Head And Neck Surgery 



Shun-Man Cheung, MD; Seng-Feng Jeng; Yur-Ren Kuo; Ching-Hua Hsien 

10:26am – 10:30am 

Discussion 

10:30am – 11:30am Presidential Address 

L. Scott Levin, MD, FACS

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 


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 


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 


of this award. 

75



Monday, January 15, 2007 

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



7:00am - 2:00pm Patient Safety Computerized Presentations Egret 

DVT Prevention 

Fire Safety 

Infection Control 

Laser Safety 

OSHA Blood Borne Pathogen Safety 


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 


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


Monday, January 15, 2007 


7:00am – 2:00pm Patient Safety Computerized Presentations 

Computerized patient safety modules will be available 

throughout the meeting for individual use 

(1 CME hour each). In addition to the CME received 

for meeting attendance, these modules will allow 

attendees to increase the designated patient safety 

CME received. 


301 Refinements in Mandible Reconstruction 

This course will give practical details and innovations 

to optimize jaw reconstruction both from the 

functional and aesthetic standpoint of view. 

Peter G. Cordeiro, MD 

Giorgio DeSantis, MD 


302 Foot and Ankle Reconstruction 

Free tissue transfer is always a considerable option for 

resurfacing extensive foot and ankle defect. Either 

muscle or skin flap has been successfully reconstructed 

the dorsal and plantar soft tissue loss. Regarding 

that the traumatized foot and ankle may have 

secondary deformaties, such as chronic osteomyelics, 

subluxation, dislocation, metatarso phalangeal joint 

dorsal contracture, a pliable skin flap will be preferred. 

Local sensate durable flap can afford a glabrous skin 

flap for managements of troplic ulcer. 

Chih-Hung Lin, MD 


Hans-Ulrich Steinau, MD 

303 Treatment of the Mutilated Hand 

Immediate and post traumatic reconstruction after 

mutilating hand injuries; strategies and treatment 

options. 



Michael Saubier, MD, PhD 

Eduardo Zancolli, III, MD 

304 Esophageal Reconstruction 

Hung-Chi Chen, MD 


305 Microsurgical Salvage of Breast Reconstruction 

Microsurgical solutions to failed implant and tissue 

breast reconstructions. 

Pierre M. Chevray, MD, PhD 



306 Microsurgical Research and Funding 

Presentation of available models for microsurgical 

research. Discussion of options for funding and 

research. 

Gregory R. D. Evans, MD, FACS 

Zoe Dailliana, MD 

William A. Zamboni, MD 

307 Facial Reanimation 


Marcus C. Ferreira, MD 


8:00am – 8:30am Past President’s Breakfast 

(by invitation only) 


308 Microsurgical Breast Reconstruction 

Review of free TRAM, DIEP and SGAP outcomes. 

Elisabeth K. Beahm, MD, FACS 

Ming Huei Cheng, MD 


77 

309 Prefabrication of Flaps 

Flap prefabrication and prelamination are advanced 

methods of reconstruction for complex defects in the 

head and neck. An update and comparison of these 

methods will be provided. 

J. Baudet, MD 



310 CPT Coding and Reimbursement 

Recommendations on how to code procedures to 

maximize reimbursement. Also, update on new 

codes for CPT 2007. 

Keith E. Brandt, MD 

Daniel J. Nagle, MD 

311 Management of Chronic Pain 

Nonoperative and operative management of neuropathic 

pain. 

David T. W. Chiu, MD 



312 Management of the Ischemic Upper Extremity 

This course addresses condition causing upper 

extremity ischemia, such as Raynaud syndrome, 

chronic renal dialysis and emboli with emphasis on 

current surgical evaluation and management. 

James Patrick Higgins, MD 

Wyndell H. Merritt, MD 


313 Sarcoma Reconstruction 

(1) Algorithms for long bone and articular reconstructions 

for bone sarcoma and (2) soft tissue sarcoma 

reconstruction to also include management of 

complications and recurrent disease. 

Joseph J. Disa, MD 

Eyal Gur, MD 


314 Pediatric Microsurgery 

To overview the current treatment of vascular 

injuries, undescended testes and facial deformations. 


Jeffrey D. Friedman, MD 

Luis Scheker, MD 



PRESENTATIONS SESSION C-1 


Moderators: Lawrence Gotlieb, MD 

Joan E. Lipa, MD, MSc, FRCS 

9:15am – 9:18am 

*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 


Yalcin Kulahci; Aleksandra Klimczak; Maria Siemionow 

9:18am – 9:21am 

*Potential Approaches to Face Harvest for Face Transplantation 


NC, USA 

Alessio Baccarani, MD; Keith E. Follmar; Jeffrey R. Marcus; Detlev Erdmann; L. 

Scott Levin 

9:21am – 9:24am 

Coronal-Posterior Approach for Facial/Scalp Flap Harvesting in Preparation for 

Facial Transplantation 


Yalcin Kulahci; Maria Siemionow; Frank Papay; Risal Djohan; Warren Hammert; 

Mark Hendrickson; James Zins 

9:24am – 9:27am 

*Donor/Recipient Compatibility and Morphological Outcomes of Face 

Transplantation: a Cadaver Study 


NC, USA 

Alessio Baccarani, MD; Keith E. Follmar; Raja R. Das; Srinivasan Mukundan; Jeffrey 

R. Marcus; L. Scott Levin; Detlev Erdmann

9:27am – 9:35am 

Discussion 

9:35am – 9:38am 

*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 

9:38am – 9:41am 

Functional Study of Motor and Sensory Recover of Facial Allotransplantation. 

Experimental Study in Rats 


Pedro C. Cavadas, MD, PhD; Luis Landin 

9:41am – 9:44am 

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 

9:44am – 9:50am 

Discussion 

9:50am – 9:53am 

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 

9:53am – 9:56am 

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 

9:56am – 9:59am 

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 

9:59am – 10:05am 

Discussion 

10:05am – 10:08am 

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, MD; Gary Arbique, PhD; Jean Gao, PhD; Dan Hatef, MD; 

Spencer Brown, PhD; Rod Rohrich, MD 

10:08am – 10:11am 

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 

10:11am – 10:14am 

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 

78 

10:14am – 10:20am 

Discussion 

10:20am – 10:23am 

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 

10:23am – 10:26am 

Adult and Children Total Phalloplasty 

Institution where the work was prepared: Clinical Center of Serbia, Belgrade, Serbia 

and Montenegro 

Marko Bumbasirevic, MD, PhD; Miroslav Djordjevic, MD, PhD; Sava Perovic, MD, 

PhD 

10:26am – 10:30am 

Discussion 

10:30am – 10:33am 

*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 

10:33am – 10:36am 

*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 

10:36am – 10:40am 

Discussion 


PRESENTATIONS SESSION C-2 


Moderators: Nicholas B. Vedder, MD 


9:15am – 9:18am 

A New Concept of Cell-Based Immunotherapy with Chimeric Cells for 

Acceptance of Composite Tissue Allograft Transplants 



Maria Siemionow, MD, PhD; Aleksandra Klimczak; Yalcin Kulahci; Galip Agaoglu; 

Anna Jankowska 

9:18am – 9:21am 

*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 

9:21am – 9:24am 

*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 

9:24am – 9:33am 

Discussion

9:33am – 9:36am 

*Fludarabine Facilitates the Nonmyeloablative Strategy and Creation of Mixed 

Chimerism to Induce Immune Tolerance to Composite Tissue Allograft 


Tayoyuan, Taiwan 

Jeng-Yee Lin, MD; Wei-Chao Huang; Chung-Rong Ho; Fu-Chan Wei; David CC 

Chuang; Ming-Huei Cheng 

9:36am – 9:39am 

*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 

9:39am – 9:45am 

Discussion 

9:45am – 9:48am 

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, 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 

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; 

Geoffrey Gurtner 

9:51am – 9:57am 

Discussion 

9:57am – 10:00am 

*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 

10:00am – 10:03am 

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, PhD; N. Berry; Christopher Chambers; MW Neumeister 

10:03am – 10:09am 

Discussion 

10:09am – 10:12am 

*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 

10:12am – 10:15am 

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, MD; Juan A. Ortiz, MD; Samir Mardini, MD; Hung-Chi 

Chen, MD, FACS; Raoul Gonzales, DVM; James R. Little, MD 

10:15am – 10:18am 

*Efficacy of Intravenous and Intraosseous Donor Bone Marrow Transplantation 

in Chimerism Induction on Vascularized Skin Allograft Transplants 



Aleksandra Klimczak, PhD; Sakir Unal; Maria Siemionow 

79 

10:18am – 10:27am 

Discussion 

10:27am – 10:30am 

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 

10:30am – 10:33am 

*Wound Healing Outcomes Following Pre-operative Radiation Therapy and 

Limb Surgery for Soft Tissue Sarcoma 


TX, USA 

Pankaj Tiwari, MD; Gurminder Singh, BA; Patrick Hsu, MD; Oluseyi Aliui, BA; 

Charles E. Butler, MD; Howard N. Langstein, MD 

10:33am – 10:40am 

Discussion 

10:40am – 11:00am Break 

11:00am – 12:00pm President’s Invited Speaker: 

Ronald M. Zuker, MD, FRCSC, FACS, FAAP 

Turtles and Challenges: A Survival Guide for the 

Young Microsurgeon 

Microsurgery need not be survival of the fittest. 

Around every bend lie opportunities to embrace, 

major challenges to solve and first smiles to enjoy. 

We will also look at 7 microsurgical areas of accomplishment 

and outline 7 more emerging areas 

for the young microsurgeon to explore. Enjoy the 

journey! 

Ronald Zuker received his MD degree from the 

University of Toronto in 1969, followed by a rotating 

internship in Vancouver, BC. After a brief period of 

family practice he pursued an interest in Anthropology 

and Jungle Medicine, spending one year working with 

the Shipibo Indians in the Amazon basin – eastern 

Peru. He then entered the McGill University program in 

Surgery and returned to the Gallie Program at the 

University of Toronto to obtain his FRCSC in 

Plastic Surgery. He received a McLaughlin Travelling 

Fellowship to pursue interests in microvascular surgery 

and pediatric plastic surgery, where he spent most of 

his time in Japan under the guidance of Dr. Kiyonori 

Harii and also in New Zealand, Australia and Europe. 

Upon returning to Canada he joined the staff of The 

Hospital for Sick Children as a consultant in Plastic 

Surgery and as Director of the Burn Unit. He was later 

appointed to the Department of Surgery of the 

University of Toronto as a lecturer in surgery, and now 

serves as Full Professor. As a staff surgeon of the 

Division of Plastic Surgery at The Hospital 

for Sick Children, Dr. Zuker practices plastic and 

reconstructive surgery exclusively in children. His 

primary interest is in facial paralysis and is the 

recognized worldwide authority for this disorder. Dr. 

Zuker is co-director of the University of Toronto 

Facial Paralysis Clinic which is the only one of its kind 

in Canada. 

12:00pm – 12:10pm “What’s New at the Meeting” 


12:15pm – 1:00pm ASRM Business Meeting (Members Only)

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, immunosuppression 

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-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. 

See page 16 for ticket information. 

80



Tuesday, January 16, 2007 

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

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



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


Tuesday, January 16, 2007 



315 Perforator Flaps 

Phillip Nicholas Blondeel, MD 

Steven Morris, MD 


316 Genitourinary Reconstruction 

The use of microsurgery in the solution of complex 

genitourinary problems will be reviewed. Topics 

include the management of post-traumatic 

vascular insufficiency, post-prostalectomy 

cavernous nerve reconstruction and complex 

congential acquised pelvic deformities. 


Gerald Jordan, MD 

317 Immunology Update 

The course will present basic aspects of immunoiogical 

responses to transplantation of composite tissue 

allografts (CTA’s). Strategies to prevent graft rejection 

will be outlined as well as side effects on immunosuppressive 

therapies. Future approaches in 

transplantation of CTA’s will be discussed. 

W.P. Andrew Lee, MD 


318 Incorporating Aesthetic Surgery in Your 

Microsurgery Practice 

Highlight the mechanisms available to enhance 

one’s micro-surgical practice with Aesthetic Surgery. 

Tips and insights. 

Joseph M. Serletti, MD, FACS 

Jeffrey D. Friedman, MD 

319 Vascularized Bone Flaps 


Konstantinos N. Malizos, MD 

Satoshi Toh, MD 

320 Non-Microsurgery for the Microsurgeon 

Christopher Attinger, MD 

Detlev Erdmann, MD 

George Psaras, MD 

321 Trunk and Chest Reconstruction 

This talk will encompass esthetic breast reconstructions, 

chest wall reconstructions due to various kinds 

of malignancies, radiation necrosis, exposure of 

heart, lung or aorta, microvascular sternal turnover 

for intractable tunnel chest, abdominal wall 

reconstructions for exposed viscera, and reconstruction 

for exposed spine, etc. 

Charles E. Butler, MD 

Yueh-Bih Tang Chen, MD, PhD 



PRESENTATIONS SESSION D-1 


Moderators: Navin Singh, MD 

Peirong Yu, MD 

8:15am – 8:18am 

Pediatric Mandibular Reconstruction with the Vascularized Fibula Flap: A 

Long-term Evaluation of Outcomes 


TX, USA 

Melissa A. Crosby, MD; Jack W. Martin; Geoffrey L. Robb, MD; David W. Chang 

82 

8:18am – 8:21am 

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 

8:21am – 8:24am 

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 

8:24am – 8:30am 

Discussion 

8:30am – 8:33am 

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 

8:33am – 8:36am 

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 

R. Vertriest, MD; JJ Vranckx, MD; MD.,PhD Vanderpoorten; G Fabre; M 

Vandevoort; P. Delaere, MD, PhD 

8:36am – 8:40am 

Discussion 

8:40am – 8:43am 

*Comparison Between Anterolateral Thigh Flap and Free Radial Forearm Flap 

For Hypopharyngeal Defect Reconstruction 



Johnson C. Yang, MD; Seng-Feng Jeng; Yur-Ren Kuo; Ching-Hua Hsien 

8:43am – 8:46am 

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 

8:46am – 8:49am 

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 Khariwala; Prashant Vivek; Ramon Esclamado, MD; Benjamin Wood; Robert 

Lorenz; Marshall Strome; Daniel Alam, MD 

8:49am – 8:52am 

Comparison Between Jejunum and Ileocolon Flaps in Terms of the Risk of Food 

Aspiration after Voice Reconstruction 


Hung-Chi Chen, MD, FACS; Yueh-Bih Tang, MD, PhD; Samir Mardini, MD; 

Christopher Salgado 

8:52am – 9:00am 

Discussion


PRESENTATIONS SESSION D-2 


Moderators: Charles Butler, MD 


8:15am – 8:18am 

Effect of Cooling on Vascular Alpha-Adrenergic Receptor-Mediated Responses 

in Primate Digital Arteries 



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 

8:18am – 8:21am 

*Ethyl Nitrite in the Management of Microsurgical Vasospasm in a Rat Model 


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 

8:21am – 8:25am 

Discussion 

8:25am – 8:28am 

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, MD; Jeffrey D. Friedman, MD; Michael Klebuc, MD 

8:28am – 8:31am 

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, PhD; Jianjun Ma; Cathy S. Carlson, PhD; Thomas L. Smith, PhD; 

L. Andrew Koman, MD 

8:31am – 8:35am 

Discussion 

8:35am – 8:38am 

*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, MD; Fábio Xerfan Nahas, PhD, MD; Marcus Vinícius Jardini 

Barbosa, PhD, MD; Eugênio Piñeda, PhD, MD; Lydia Masako Ferreira, PhD, MD 

8:38am – 8:41am 

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 

8:41am – 8:44am 

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; Ruben N. Gonzalez, MD; A. Scott LaJoie, PhD, MSPH; Dan 

Hatef, MD; Michel Saint-Cyr, MD 

8:44am – 8:50am 

Discussion 

83 

8:50am – 8:53am 

*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; Batia Yafe, MD; Arie Orenstain, MD, Profesor 

8:53am – 8:56am 

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 

8:56am – 9:00am 

Discussion 

9:10am – 10:10am Panel: Optimizing Results in Head and Neck 


Panel will discuss tracks and approaches to optimize 

outcome and minimize donor morbidity. 

Peter C. Neligan, MD, Moderator 

Ralph Gilbert, MD 

Ron Yu, MD 


10:30am – 11:30am Panel: Facial Transplantation – Where 

are we headed? 

The panel will discuss current the current status of facial 

transplantation with a presentation of advancement in 

experimental and clinical protocols, as well as discussion 

of ethical and other related issues. 

Maria Siemionow, MD, PhD, Moderator 


Marco Lanzetta, MD 

11:30am - 11:35am ASRM Military Liaison Initiative 


11:35am - 11:38am ASRM Microsurgery Mission Initiative 

Fred Duffy, MD 

11:38am – 12:38pm Buncke Lecture: James Urbaniak, MD 

The Harry Buncke Lectureship has been created with the 

support of the California Pacific Medical Center to honor 

Dr. Buncke's remarkable contributions fo the field of 

microsurgery. Dr. Harry Buncke has played a major role 

in the development of our specialty and has helped 

develop several microsurgical laboratories across the 

globe. He has influenced countless residents and 

fellows as well as numerous department chairs throughout 

the world. It is with great appreciation that we are 

able to honor Dr. Harry Buncke with this lectureship due 

to the sponsorship of the California Pacific Medical Center. 

It is our pleasure to introduce James Urbaniak, MD 

as the 2007 Harry Buncke Lecturer. 

The Perfect Virtue 

A past president of the ASRM, Dr. Urbaniak is recognized 

as a pioneer in the replantation of severed digits 

and hands. For the past 36 years he has conducted 

significant research in the area of microsurgical reconstruction 

of traumatized extremities and avascular necrosis 

of the femoral head. He was one of the first medical 

researchers in the world to develop and refine these techniques 

and as a result, the principles and guidelines he 

established for microsurgery are widely accepted and used. 

Dr. Urbaniak received his Doctor of Medicine from Duke 

University School of Medicine where he completed his 

surgical internship and orthopaedic surgery residency, and 

eventually joined the faculty. Dr. Urbaniak is the Virginia 

Flowers Baker Professor of Orthopaedic Surgery and 

President Elect of the International Federation of Societies 

for Surgery of the Hand. 

The ASRM would like to thank the 

California Pacific Medical Center for 

their generous sponsorship of this 

Buncke Lecture. 

1:00pm - 3:00pm Narakas Society Guest Panel 

The panel will focus on facts as opposed to opinion and 

controversies, e.g., indications, timing of nerve reconstruction, 

treating sequellae, etc. 


Alain Gilbert, MD 

Julia Terzis, MD, PhD 

Peter Waters, MD 

3:00pm Meeting Adjourned

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

Author Index 

Aarabi, Shahram . . . . . . . . . . . . . . . . . . . .172 

Adamany, Damon C. . . . . . . . . . . . . . . . . 96 

Adani, Roberto . . . . . . . . . . . . . . . . . . . 150 

Agaoglu, Galip . . . . . . . . . . . . . . . 163, 169 

Agrestic, Michael . . . . . . . . . . . . . . . . . . . 99 

Akelina, Yelena . . . . . . . . . . . . . . . . . . . 134 

Al-Attar, Ali . . . . . . . . . . . . . . . . . . . . . . 127 

Alaid, A. O. . . . . . . . . . . . . . . . . . . . . . . 123 

Alam, Daniel . . . . . . . . . . . . . . . . . . . . . 179 

Aldridge III, Julian McClees . . . . . . . . . . 149 

Alfonso, Israel . . . . . . . . . . . . . . . . 118, 147 

Aliui, Oluseyi . . . . . . . . . . . . . . . . . . . . . 175 

Alon, Malvina . . . . . . . . . . . . . . . . . . . . 159 

Amir, Aharon . . . . . . . . . . . . . . . . . . . . . 149 

Amiri, Farhad A. . . . . . . . . . . . . . . . . . . 173 

Amrami, Kimberly K. . . . . . . . . 87, 120, 128 

An, Kai-Nan . . . . . . . . . . . . . . . . . . 87, 106 

Ansorge, Heather L. . . . . . . . . . . . . . . . . . 92 

Arbique, Gary . . . . . . . . . . . . . . . . . . . . 166 

Arcocha, Juan . . . . . . . . . . . . . . . . . . . . 164 

Ardelean, Filip . . . . . . . . . . . . . . . . . 94, 102 

Atkinson, Denis . . . . . . . . . . . . . . . . . . . 119 

Atroshi, Isam . . . . . . . . . . . . . . . . . . . . . . 97 

Aubá, Cristina . . . . . . . . . . . . . . . . . . . . 164 

Baccarani, Alessio . . . . . .150, 160, 161, 180 

Bach, Harold Gregory . . . . . . . . . . . . . . 138 

Bach, Joel . . . . . . . . . . . . . . . . . . . . . . . . 90 

Backus-Saccoliti, Sherri I. . . . . . . . . . . . 105 

Badalamente, Marie . . . . . . . . . . . . . . . . 91 

Bae, Donald S. . . . . . . . . . . . . . . . . . . . . 94 

Bain, James . . . . . . . . . . . . . . . . . . . . . . 129 

Bajaj, Anureet . . . . . . . . . . . . . . . . . . . . 142 

Baldini, Todd . . . . . . . . . . . . . . . . . . . . . 90 

Bamberger, HB . . . . . . . . . . . . . . . . . . . 100 

Barbe, Mary F. . . . . . . . . . . . . . . . . . . . . . 99 

Barbosa, Marcus Vinícius Jardini . . . . . . 182 

Barker, Allison R. . . . . . . . . . . . . . . 124, 139 

Barnea, Yoav . . . . . . . . . . . . . . . . . . . . . 149 

Barr, Ann E. . . . . . . . . . . . . . . . . . . . . . . 99 

Barreto, Andre . . . . . . . . . . . . . . . . . . . . 107 

Baumeister, Steffen P. . . . . . . . . . . . . . . 150 

Bayat, Ardeshir . . . . . . . . . . . . . . . . 90, 112 

Becker, Stefan . . . . . . . . . . . . . . . . . . . . 123 

Bednar, John M. . . . . . . . . . . . . . . . . . . . 96 

Belzberg, Allan J. . . . . . . . . . . . . . . . . . 137 

Bengaard, Jens . . . . . . . . . . . . . . . . . . . 168 

Bengtson, Keith A. . . . . . . . . . . . . . . . . 120 

Beredjiklian, Pedro K. . . . . . . . . . . . . . . . 92 

Berger, Evelyn . . . . . . . . . . . . . . . . . . . . 106 

Berger, Richard A. . . . . . . . . . . . 87, 88, 106 

Berry, N. . . . . . . . . . . . . . . . . . . . . . . . . 173 

Bezuhly, Michael . . . . . . . . . . . . . . . . . . . 95 

Bhuller, Amardip . . . . . . . . . . . . . . . . . . 157 

Bickel, Brent A. . . . . . . . . . . . . . . . . . . . . 96 

Bickel, Kyle . . . . . . . . . . . . . . . . . . . . . . 108 

Bickels, Jacob . . . . . . . . . . . . . . . . . . . . 149 

Biernaskie, J. . . . . . . . . . . . . . . . . . . . . . 134 

Bishop, Allen T. . . . . . . . . . . . . . . . . . . . 102 

Bluebond-Langner, Rachel . . .154, 155, 157 

Boddeke, H. W. G. M. . . . . . . . . . . . . . . 133 

Boer, Gerard J . . . . . . . . . . . . . . . . . . . . 116 

Bois, John P. . . . . . . . . . . . . . . . . . . . . . 122 

Bonillas, Robert G. . . . . . . . . . . . . . . . . 172 

Botts, Jonathon Devlin . . . . . . . . . . . . . . 89 

Boviatsis, Efstathios . . . . . . . . . . . . . . . . 128 

Boydston, William . . . . . . . . . . . . . . . . . 119 

Braccini, Alessandra . . . . . . . . . . . . . . . . 171 

Bravo, Cesar J. . . . . . . . . . . . . . . . . . . . . 102 

Brockardt, Chad . . . . . . . . . . . . . . . . . . . 93 

Brooks, Darrell . . . . . . . . . . . . . . . . 146, 182 

Brown, Spencer . . . . . . . . . . . . . . . . . . . 166 

Browne, Earl . . . . . . . . . . . . . . . . . . . . . 157 

Bruen, Kevin J. . . . . . . . . . . . . . . . . . . . 175 

Brunelli, Giorgio . . . . . . . . . . . . . . . . . . 117 

Bueno, Reuben . . . . . . . . . . . . . . . . . . . . 98 

Bullocks, Jamal . . . . . . . . . . . . . . . . . . . 181 

Bumbasirevic, Marko . . . . . . . . . . . . . . . 167 

Buncke, Gregory M. . . . . . . . . . . . . . . . 147 

Buntic, Rudolf F. . . . . . . . . . . 146, 147, 182 

Bushnell, Brandon DuBose . . . . . . . . . . 108 

Butler, Charles E. . . . . . . . . . . . . . . . . . .175 

Callahan, Michael F. . . . . . . . . . . . . . . . 180 

Camberos, Alfonso . . . . . . . . . . . . . . . . 147 

Capota, Irina . . . . . . . . . . . . . . . . . . 94, 102 

Cardenas-Mejia, Alexander . . . . . . . . . . 116 

Carlson, Cathy S. . . . . . . . . . . . . . . . . . . 181 

Carter, Timothy I. . . . . . . . . . . . . . . . . . 105 

Cartwright, Michael S. . . . . . . . . . . . . . . 126 

85 

Carvalho, Alex . . . . . . . . . . . . . . . . . . . 94 

Cavadas, Pedro C. . . . . . . . . . . . 150, 163 

Ceradini, Daniel J. . . . . . . . . . . . . . . . 172 

Cetrulo Jr, Curtis L. . . . . . . . . . . . . . . 158 

Chambers, Christopher . . . . . . . . 134, 172 

Chan, Jeff . . . . . . . . . . . . . . . . . . . . . . 93 

Chang, Benjamin . . . . . . . . . . . . . . . . 159 

Chang, David W. . . . . . . . . . . . . . . . . 176 

Chang, Hui-Hsiu . . . . . . . . . . . . . . . . . 117 

Chang, James . . . . . . . . . . . . . . . . . . . . 92 

Chang, Nai-Jen . . . . . . . . . . . . . 164, 170 

Chang, Yang-Ming . . . . . . . . . . . . . . . 176 

Chao, Moses . . . . . . . . . . . . . . . . . . . . 129 

Chavez, Eva . . . . . . . . . . . . . . . . . 98, 113 

Chen Tang, Yueh-Bih . . . . . . . . . . . . . 117 

Chen, Constance M. . . . . . . . . . . . . . . 141 

Chen, Hung-Chi . . . . . . . . . 167, 174, 179 

Chen, Kuang-Te . . . . . . . . . . . . . . . . . 116 

Chen, Lun . . . . . . . . . . . . . . . . . . . . . 137 

Chen, Michael . . . . . . . . . . . . . . . . . . . 101 

Chen, Ming-Ting . . . . . . . . . . . . . . . . 156 

Chen, Shun-Sheng . . . . . . . . . . . . . . . 132 

Cheng, Ming-Huei . . . . . . . . . . . 155, 170 

Cheng, Nai-Chen . . . . . . . . . . . . . . . . 156 

Cheung, Shun-Man . . . . . . . . . . . . . . 160 

Chevray, Pierre . . . . . . . . . . . . . . . . . . 142 

Chien, Chih-Yen . . . . . . . . . . . . . . . . . 179 

Chiu, Ernest S. . . . . . . . . . . . . . . . . . . 146 

Chloros, G.D. . . . . . . . . . . . . . . . 126, 150 

Chuang, Chwei-Chin . . . . 116, 149, 155, 165, 170 

Chudnovsky, Nachum . . . . . . . . . . . . . 127 

Clavero, J. A. . . . . . . . . . . . . . . . . . . . 140 

Cobb, Tyson . . . . . . . . . . . . . . . . 100, 115 

Cohen, Akiva S. . . . . . . . . . . . . . . . . . 133 

Colman, Matthew . . . . . . . . . . . . . . . . 103 

Cooney, Damon . . . . . . . . . . . . . . 98, 173 

Copray, J.C.V.M. . . . . . . . . . . . . . . . . . 133 

Cordeiro, Peter G. . . . . . . . . . . . . . . . . 141 

Crosby, Melissa A. . . . . . . . . . . . . . . . . 176 

Cui, XD . . . . . . . . . . . . . . . . . . . . . . . . 102 

Czermak, Christoph . . . . . . . . . . . . . . 158 

Dahl, William . . . . . . . . . . . . . . . . . . . . 96 

Dai, Qiang . . . . . . . . . . . . . . . . . . . . . . 93 

Das, Raja R. . . . . . . . . . . . . . . . . . . . . 162 

Day, Joe P. . . . . . . . . . . . . . . . . . . . . . 145 

De Ruiter, Godard C.W. . . . . . . . 122, 123 

De Santis, Giorgio . . . . . . . . . . . . . . . . 150 

Delaere, P. . . . . . . . . . . . . . . . . . 177, 178 

Dellon, A. Lee . . . . . . . . . . . . . . . 124, 139 

DeSilva, Gregory L. . . . . . . . . . . . . . . . . 87 

Desy, Nicholas M. . . . . . . . . . . . . . . . . 128 

Deune, E. Gene . . . . . . . . . . . . . . . . . . 96 

Deveci, Mustafa . . . . . . . . . . . . . 165, 167 

Dhar, Sanjay . . . . . . . . . . . . . . . . . . . . 130 

Diaz, Veronica . . . . . . . . . . . . . . . . . . 107 

Diaz, Otoniel . . . . . . . . . . . . . . . . . . . 147 

Dietz, Klaus . . . . . . . . . . . . . . . . . . . . 123 

Disa, Joseph J. . . . . . . . . . . . . . . . . . . 141 

Djohan, Risal . . . . . . . . . . . . . . . 157, 162 

Djordjevic, Miroslav . . . . . . . . . . . . . . 167 

Dormans, John P. . . . . . . . . . . . . . . . . 159 

Dorsi, Michael . . . . . . . . . . . . . . . . . . 137 

Dosanjh, Amarjit S. . . . . . . . . . . . . . . . 108 

Doser, Michael . . . . . . . . . . . . . . . . . . 123 

Draganich, Louis . . . . . . . . . . . . . . . . . 103 

Ducic, Ivica . . . . . . . . . . . . . . . . . . . . . 127 

Dy, Christopher J. . . . . . . . . . . . . . . . . 107 

Dyck, P.J. . . . . . . . . . . . . . . . . . . . . . . 123 

Eckman, Delrae M. . . . . . . . . . . . . . . . 180 

Edwards, Michael Charles . . . . . . . . . . 145 

El Hassan, Bassem . . . . . . . . . . . . . . . 138 

El-Sabbagh, Ahmed . . . . . . . . . . . . . . 180 

Engelstad, J.K. . . . . . . . . . . . . . . . . . . 123 

Erdmann, Detlev . . . . . . . . . 161, 162, 180 

Esclamado, Ramon . . . . . . . . . . . . . . . 179 

Evans, Gregory RD . . . . . . . . . . . 130, 163 

Fabre, Gerd . . . . . . . . . . 144, 177, 178 

Fahnestock, Margaret . . . . . . . . . . 129 

Fedorczyk, Jane M. . . . . . . . . . . . . . 99 

Feili-Hariri, Maryam . . . . . . . . . . . . 171 

Feirabend, H.K.P. . . . . . . . . . . . . . .123 

Feng, Guan-Ming . . . . . . . . . . . . . . . . . . 167 

Ferreira, Lydia Masako . . . . . . . . . . . . . . . 182 

Fink, BF . . . . . . . . . . . . . . . . . . . . . . . . . . 102 

Firoozbakhsh, Keikhosrow . . . . . . . . . 94, 112 

Fishman, Elliot K. . . . . . . . . . . . . . . . . . . . 140 

Follmar, Keith E. . . . . . . . . . . . 161, 162, 180 

Fox, Ida K. . . . . . . . . . . . . . . . . . . . . . . . . 134 

Freiman, Jacob J. . . . . . . . . . . . . . . . . . . . 147 

Friedman, Jeffrey D. . . . . . . . . . . . . . . . . . 181 

Frijters, Erik . . . . . . . . . . . . . . . . . . . . . . . 152 

Fuloria, Mamta . . . . . . . . . . . . . . . . . . . . 180 

Gaertner, Jamie D. . . . . . . . . . . 121, 135, 136 

Galaviz, Paula . . . . . . . . . . . . . . . . . . . . . . 99 

Gao, Dy . . . . . . . . . . . . . . . . . . . . . . . . . . 102 

Gao, Jean . . . . . . . . . . . . . . . . . . . . . . . . 166 

Gasser, Juerg A. . . . . . . . . . . . . . . . . . . . . 171 

Gautam, Abhinav K. . . . . . . . . . . . . . . . . 146 

Georgescu, Alexandru . . . . . . . . . . . . 94, 102 

Gerhardt Summers Helena . . . . . . . . . . . . 120 

Germann, Günter . . . . . . . . . . . . . . . 106, 158 

Gerostathopoulos, Nikolaos . . . . . . . . . . . 128 

Giannoulis, Filippos S. . . . . . . . . . . . . 95, 103 

Gonzales, Raoul . . . . . . . . . . . . . . . . . . . . 174 

Gonzalez, Mark . . . . . . . . . . . . . . . . . . . . 138 

Gonzalez, Ruben N. . . . . . . . . . . . . . . . . . 183 

Goodwin, Adam . . . . . . . . . . . . . . . . . . . . . 88 

Gorría, Oscar . . . . . . . . . . . . . . . . . . . . . . 164 

Grady, M. Sean . . . . . . . . . . . . . . . . . . . . 133 

Graif, Moshe . . . . . . . . . . . . . . . . . . 126, 127 

Greenberg, Jeffrey A. . . . . . . . . . . . . . . . . . 89 

Greives, Matthew R. . . . . . . . . . . . . . . . . . 158 

Groff, Robert G. . . . . . . . . . . . . . . . . . . . . 133 

Grossman, John. A. I. . . . . . . . . . . . . . . . . 118 

Gupta, Dhanesh K. . . . . . . . . . . . . . . . . . . 175 

Gur, Eyal . . . . . . . . . . . . . . . . . . . . . . . . . 149 

Gurtner, Geoffrey . . . . . . . . . . . . . . . . . . . 172 

Gyovai, James . . . . . . . . . . . . . . . . . . . . . . 95 

Hadlock, Tessa A. . . . . . . . . . . . . . . . . . . . 132 

Haerle, Max . . . . . . . . . . . . . . . . . . . . . . . 123 

Halvorson, Eric . . . . . . . . . . . . . . . . . . . . . 141 

Hamdi, Moustapha . . . . . . . . . . . . . . . . . 145 

Hammert, Warren . . . . . . . . . . . . . . . . . . 162 

Hamou, Cynthia . . . . . . . . . . . . . . . . . . . . 172 

Handy, Marcus J. . . . . . . . . . . . . . . . . . . . . 99 

Hansen, Scott L. . . . . . . . . . . . . . . . . . . . . 108 

Harrison, Heather . . . . . . . . . . . . . . . . . . . 138 

Hatef, Dan . . . . . . . . . . . . . . . . 111, 166, 183 

Hayashi, Ayato . . . . . . . . . . . . . 121, 131, 135 

Hayes, Austin G. . . . . . . . . . . . . . . . . . . . 134 

Hazan, André Salo Buslik . . . . . . . . . . . . . 182 

Heaton, James T. . . . . . . . . . . . . . . . . . . . 132 

Heberer, Michael . . . . . . . . . . . . . . . . . . . 171 

Heckler, Matthew . . . . . . . . . . . . . . . . . . . 100 

Hegde, Jagadish . . . . . . . . . . . . . . . . . . . . 172 

Heitmann, Christoph . . . . . . . . . . . . . . . . 158 

Hendrickson, Mark . . . . . . . . . . . . . . . . . . 162 

Hentz, Vincent R. . . . . . . . . . . . . . . . . . . . 92 

Herrand, Hector . . . . . . . . . . . . . . . . . . . . 147 

Herrera Jr, Fernando A. . . . . . . . . . . . . . . 147 

Higgins, Amanda . . . . . . . . . . . . . . . . . . . . 95 

Hillstrom, Howard J. . . . . . . . . . . . . . . . . 105 

Hindocha, Sandip . . . . . . . . . . . . . . . . 90, 112 

Ho, Chung-Rong . . . . . . . . . . . . . . . 164, 170 

Hofer, Stefan O.P. . . . . . . . . . . . . . . . . . . 152 

Hofstede-Buitenhuis, S.M . . . . . . . . . . . . . 119 

Holden, Martha . . . . . . . . . . . . . . . . . . . . 150 

Hontanilla, Bernardo . . . . . . . . . . . . . . . . 164 

Horibe, Elaine . . . . . . . . . . . . . . . . . . . . . 171 

Horton, Joseph . . . . . . . . . . . . . . . . . . . . . 87 

Horton, Karen M. . . . . . . . . . . . . . . . 146, 182 

Howell, Julianne . . . . . . . . . . . . . . . . . . . . 95 

Hsieh, Ching-Hua . . . . . . . . . . . . . . . . . . 132 

Hsieh, Yu-Hsuan . . . . . . . . . . . . . . . 164, 170 

Hsien, Ching-Hua . . . . . . . . . . . . . . 177, 178 

Hsu, Patrick . . . . . . . . . . . . . . . . . . . . . . . 175 

Huang, Jason H. . . . . . . . . . . . . . . . . . . . 133 

Huang, Wei-Chao . . . . . . . . . . 164, 169, 170 

Huber, Christina . . . . . . . . . . . . . . . . . . . . . 87 

Hubert, Darrin M. . . . . . . . . . . . . . . . . . . 159 

Hunter, Daniel A. . . . 121, 130, 134, 135, 136 

Hurst, Lawrence . . . . . . . . . . . . . . . . . . . . . 91 

Hussey, Alan . . . . . . . . . . . . . . . . . . . . . . 129 

Ikegami, Hiroyasu . . . . . . . . . . . . . . . . . . 106 

Ikeguchi, Ryosuke . . . . . . . . . . . . . . . . . . 171 

Ingold, Peter . . . . . . . . . . . . . . . . . . . . . . 171 

Innocenti, Marco . . . . . . . . . . . . . . . . . . . 150 

Jafari Saraf, Lida . . . . . . . . . . . . . . . . . . . 119 

Janevski, Peter . . . . . . . . . . . . . . . . . . . . . . 96 

Jankowska, Anna . . . . . . . . . . . . . . . . . . . 169 

Jaquiery, Claude . . . . . . . . . . . . . . . . . . . .171 

Jebson, Peter J. L. . . . . . . . . . . . . . . 108 

Jeng, Seng-Feng . 132, 160, 164, 170, 177, 178 

Jobin, Charles M. . . . . . . . . . . . . . . 134 

Jones, Neil F. . . . . . . . . . . . . . . . . . . 147 

Jung, Shih-Ming . . . . . . . . . . . . . . . 165 

Kaarela, Outi . . . . . . . . . . . . . . . . . . 151 

Kao, Dennis . . . . . . . . . . . . . . . . . . . . 99 

Kardestuncer, Tarik . . . . . . . . . . . . . . 94 

Kaufman, K. R. . . . . . . . . . . . . . . . . 123 

Keirstead, Hans S. . . . . . . . . . . . . . . 130 

Kelly, Jack L. . . . . . . . . . . . . . . . . . . . 93 

Kemp, Stephen W.P. . . . . . . . . . . . . 136 

Kerns, James M. . . . . . . . . . . . . . . . 138 

Khan, Farah Naz . . . . . . . . . . . 143, 145 

Khariwala, Samir . . . . . . . . . . . . . . . 179 

Khuthaila, Dana K. . . . . . . . . . . . . . 145 

Kilic, Abdullah . . . . . . . . . . . . . . . . . 165 

Kimura, Naohiro . . . . . . . . . . . . . . . 166 

Kiran, Ravi . . . . . . . . . . . . . . . . . . . . . 98 

Kjellin, Ingrid . . . . . . . . . . . . . . . . . . 107 

Klebuc, Michael . . . . . . . . . . . . 153, 181 

Klimczak, Aleksandra 161, 163, 169, 174 

Klitzman, Bruce . . . . . . . . . . . . . . . . 180 

Kollender, Yehuda . . . . . . . . . . . . . . 149 

Koman, L. Andrew . . . . . . . . . . . . . . 150 

Koob, Jason W. . . . . . . . . 121, 131, 135 

Kosins, Aaron M. . . . . . . . . . . . . . . . 130 

Kostopoulos Epaminondas . . . . . . . 151 

Kotajarvi, Brian . . . . . . . . . . . . . . . . 120 

Kovach, Stephen . . . . . . . . . . . . . . . 180 

Kraisarin, Jirachart . . . . . . . . . . . . . . 106 

Krishnan, Kartik . . . . . . . . . . . . . . . . 129 

Kryger, Gil S. . . . . . . . . . . . . . . . . . . 159 

Kubo, Tateki . . . . . . . . . . . . . . . . . . 122 

Kueh, Nai-Siong . . . . . . . . . . . . . . . 179 

Kulahci, Yalcin . 138, 139, 161, 162, 169 

Kuo, Yur-Ren . 160, 165, 177, 178, 179 

Kurt, Bulent . . . . . . . . . . . . . . . . . . 165 

Kwon, Yong . . . . . . . . . . . . . . . . . . . . 89 

Lai, Chao-Yi . . . . . . . . . . . . . . . . . . 148 

LaJoie, A. Scott . . . . . . . . . . . . . . . . 183 

Lakke, E. A. J. F. . . . . . . . . . . . . . . . 123 

Lalonde, Donald H. . . . . . . . 95, 98, 115 

Lalonde, Janice . . . . . . . . . . . . . 98, 115 

Landin, Luis . . . . . . . . . . . . . . . . . . . 163 

Langstein, Howard N. . . . . . . . . . . . 175 

Lannon, Declan A. . . . . . . . . . . . . . . 153 

Latta, Loren . . . . . . . . . . . . . . . . . . . 107 

laurentin, luis . . . . . . . . . . . . . . . . . . 88 

le Cessie, S. . . . . . . . . . . . . . . . . . . . 119 

LeBlanc, Martin R. . . . . . . . . . . . 98, 115 

Lee, Charles K. . . . . . . . . 147, 159, 182 

Lee, W.P. Andrew . . . . . . . . . . . . . . . 171 

Lenhoff, Mark W. . . . . . . . . . . . . . . 105 

Lerman, Oren Z. . . . . . . . . . . . . . . . 158 

Leshem, David . . . . . . . . . . . . . . . . . 149 

Letourneau, Peter Robert . . . . . . . . 173 

Leven, Robert M. . . . . . . . . . . . . . . . 138 

Levin, L. Scott . . . . . . . . . . . . . . . . . . 89 

Levine, Jamie P. . . . . . . . . . . . . . . . 158 

Levine, Joshua L. . . . . . . . . . . . . . . . 146 

Li, Zhongyu . . . . . . . . . . . . . . . . . . . 181 

Liechty, Kenneth W. . . . . . . . . . . . . . . 92 

Lifchez, Scott . . . . . . . . . . . . . . . . . . 99 

Lin, Cheng-Hung . . . . . . . . . . . . . . 148 

Lin, Chih-Hung . . . . . . . . . . . . . . . . 148 

Lin, Chun-Yen . . . . . . . . . . . . . . . . . 169 

Lin, Jeng-Yee . . . . . . . . . . . . . . . . . 170 

Lin, Yu-Te . . . . . . . . . . . . . . . . 116, 148 

Little, James R. . . . . . . . . . . . . . . . . 174 

Liu, Daniel Z. . . . . . . . . . . . . . . 121, 135 

Lorenz, Robert . . . . . . . . . . . . . . . . . 179 

Low, David W. . . . . . . . . . . . . . . . . . 159 

Lu, Hung-I . . . . . . . . . . . . . . . . . . . 179 

Lu, Linda . . . . . . . . . . . . . . . . . . . . . 171 

Lu, Tsu-Hsiang . . . . . . . . . . . . . . . . 132 

Lucas, Robert M. . . . . . . . . . . . . . . . 150 

Lyu, Rong-Kuo . . . . . . . . . . . . . . . . 165 

Ma, Jianjun . . . . . . . . . . . . . . . . . . . 181 

Ma, M.S. . . . . . . . . . . . . . . . . . . . . . 133 

Macheras, George . . . . . . . . . . . . . . 128 

Mackinnon, Susan E. . 121, 130, 131, 134, 135, 154 

Maghari, Ahmad . . . . . . . . . . . . . . . 119 

Makowski, Anna-Lena . . . . . . . . . . . 107 

Malessy, M.J.A. . . . . . . . . . . . . 118, 119 

Malik, Ali . . . . . . . . . . . . . . . . . . . . . 107 

Maloney-Wilensky, Eileen . . . . . . . . 133 

Man, Li-Xing . . . . . . . . . . . . . . . . . . 141 

Manson, Paul N. . . . . . . . . . . . . . . . 155 

Marcus, Jeffrey R. . 96, 161, 162, 182

Mardinis, Samir . . . . . . . . . . . . . . . . . . 167 

Marechant-Hanson, Judith . . . . . . . . . . 99 

Martin, Ivan . . . . . . . . . . . . . . . . . . . . . 171 

Martin, Jack W. . . . . . . . . . . . . . . . . . . 176 

Masia, Jaume . . . . . . . . . . . . . . . . . . . . 140 

Mass, Daniel Paul . . . . . . . . . . . . . . . . . 103 

Massey, Marga F. . . . . . . . . . . . . . . . . . 175 

Matei, Ileana . . . . . . . . . . . . . . . . . 94, 102 

Matloub, Hani S. . . . . . . . . . . . . . . 99, 125 

McAdams, Timothy R. . . . . . . . . . . . . . . 92 

McCabe, Steven J. . . . . . . . . . 97, 110, 150 

McCampbell, Beth . . . . . . . . . . . . . . . . . 98 

McCarthy, Joseph G . . . . . . . . . . . . . . . 154 

McConnell, Michael P. . . . . . . . . . . . . . 130 

McWilliams, Andrew . . . . . . . . . . . . . . . 108 

Meek, M. F. . . . . . . . . . . . . . . . . . . . . . 133 

Mehrara, Babak J. . . . . . . . . . . . . . . . . 141 

Meilik, Benjamin . . . . . . . . . . . . . . . . . 183 

Meller, Izzac . . . . . . . . . . . . . . . . . . . . . 149 

Mendoza, Charles . . . . . . . . . . . . . . . . 130 

Mercer, Deana . . . . . . . . . . . . . . . . 94, 112 

Messer, Terry M. . . . . . . . . . . . . . . . . . . 108 

Messina, Aurora . . . . . . . . . . . . . . . . . . 129 

Meyer, Richard . . . . . . . . . . . . . . . . . . . 137 

Michalski, Bernadeta . . . . . . . . . . 129, 136 

Midha, Raj . . . . . . . . . . . . . . . . . . 134, 136 

Midha, Rajiv . . . . . . . . . . . . . . . . . . . . . 120 

Miller, F. . . . . . . . . . . . . . . . . . . . . . . . . 134 

Milne, Edward . . . . . . . . . . . . . . . . . . . 107 

Mirza, M. Ather . . . . . . . . . . . . . . . . . . . 90 

Mithani, Suhail K. . . . . . . . . . . . . . . . . 154 

Mitra, Amit . . . . . . . . . . . . . . . . . . . . . . 98 

Mitra, Avir . . . . . . . . . . . . . . . . . . . . . . 113 

Molski, Michal . . . . . . . . . . . . . . . 138, 139 

Moneim, Moheb S. . . . . . . . . . . . . . 94, 112 

Monsivais, Jose . . . . . . . . . . . . . . . 97, 137 

Monstrey, Stan . . . . . . . . . . . . . . . . . . . 145 

Moon, Wong . . . . . . . . . . . . . . . . . . . . 157 

Moradzadeh, Arash . . . 121, 130, 131, 135 

Moran, Steven L. . . . . . . . . . . . . . 102, 104 

Morrison, Wayne . . . . . . . . . . . . . . . . . 129 

Mountcastle, Timothy S. . . . . . . . . . . . 146 

Mourouzis, Iordanis . . . . . . . . . . . . . . . 128 

Mourouzis, Kostas . . . . . . . . . . . . . . . . 128 

Mowbray, John G. . . . . . . . . . . . . . . . . . 96 

Mueller, Hans-Werner . . . . . . . . . . . . . 123 

Mujadzic, Mirsad . . . . . . . . . . . . . . . . . 183 

Mukundan, Srinivasan . . . . . . . . . . . . . 162 

Mureau, Marc A.M. . . . . . . . . . . . . . . . 152 

Murray, Peter M. . . . . . . . . . . . . . . . . . 108 

Musial, Joseph . . . . . . . . . . . . . . . . . . . . 96 

Myckatyn, Terence M. . . . . . 121, 131, 135 

Müller, Miriam . . . . . . . . . . . . . . . . . . . 106 

Nahas, Fábio Xerfan . . . . . . . . . . . . . . . 182 

Nakamichi, Noriaki . . . . . . . . . . . . . . . . 106 

Nakamura, Toshiyasu . . . . . . . . . . . . . . 106 

Nalbantis, Emilios . . . . . . . . . . . . . . . . 158 

Neligan, Peter C. . . . . . . . . . . . . . . . . . 153 

Nelson, Cory Oliver . . . . . . . . . . . . . . . . 89 

Neumeister, Michael W . . . . . . . . . 98, 172 

Nguyen, Minh-Doan . . . . . . . . . . . . . . 172 

Nguyen, Minhthy . . . . . . . . . . . . . . . . . 107 

Nichols, Christopher M. . . . . . . . . . . . . 135 

Novak, Christine B. . . . . . . . . . . . . . . . . 153 

Ntallas, Dimitrios . . . . . . . . . . . . . . . . . 128 

Nunley, James A. . . . . . . . . . . . . . . . . . 149 

Nuñez, MD, Marcos . . . . . . . . . . . . . . . 147 

Okuyama, Noriko . . . . . . . . . . . . . . . . . 106 

Olbrich, Kevin C. . . . . . . . . . . . . . . . . . 180 

Orenstain, Arie . . . . . . . . . . . . . . . . . . . 183 

Ortiz, Juan A. . . . . . . . . . . . . . . . . . . . . 174 

Oser, Craig . . . . . . . . . . . . . . . . . . . . . . . 96 

Ouellette, E. Anne . . . . . . . . . . . . . . . . 107 

Ozdag, Fatih . . . . . . . . . . . . . . . . . . . . 165 

Ozturk, Serdar . . . . . . . . . . . 158, 165, 167 

Pan, Chun-Hao . . . . . . . . . . . . . . . . . . 149 

Pansy, Brian . . . . . . . . . . . . . . . . . . . . . 105 

Pantos, Constantinos . . . . . . . . . . . . . . 128 

Papakostas, Ioannis . . . . . . . . . . . . . . . 128 

Papay, Frank . . . . . . . . . . . . . . . . . . . . 162 

Park, Julie E. . . . . . . . . . . . . . . . . . . . . 155 

Pego, Ana P. . . . . . . . . . . . . . . . . . . . . 123 

Perovic, Sava . . . . . . . . . . . . . . . . . . . . 167 

Pfister, Bryan J. . . . . . . . . . . . . . . . . . . 133 

Pierer, Gerhard . . . . . . . . . . . . . . . . . . . 171 

Pihur, Vasyl . . . . . . . . . . . . . . . . . . . . . . 97 

Pinelli, Massimo . . . . . . . . . . . . . . . . . . 150 

Piñeda, Eugênio . . . . . . . . . . . . . . . . . . 182 

Pondaag, Willem . . . . . . . . . . . . . .118, 119 

86 

Pusic, Andrea L. . . . . . . . . . . . . . . . . . . .141 

Randolph, Mark . . . . . . . . . . . . . . . . . . 122 

Raphael, James . . . . . . . . . . . . . . . . . . . 101 

Reddy, Sudheer . . . . . . . . . . . . . . . . . . . 92 

Regan, Padraic J . . . . . . . . . . . . . . . . . . 93 

Reinhart, Mary Kate . . . . . . . . . . . . . . . . 90 

Ricchetti, Eric T. . . . . . . . . . . . . . . . . . . . 92 

Riley, Danny A. . . . . . . . . . . . . . . . 99, 125 

Rinker, Brian . . . . . . . . . . . . . . . . . . . . . 102 

Riordan, Colin L. . . . . . . . . . . . . . . . . . . 93 

Rizzo, Marco . . . . . . . . . . . . . . . . . . . . 104 

Robb, Geoffrey L. . . . . . . . . . . . . . . . . . 176 

Robinson, Kris . . . . . . . . . . . . . . . . 97, 137 

Roche, Nathalie . . . . . . . . . . . . . . . . . . 145 

Rochkind, Shimon . . . . . . . . . . . . 126, 127 

Rodriguez, Edgardo R. . . . . . . . . . . . . . 139 

Rodriguez, Eduardo D. . . . . . 154, 155, 157 

Roesner, Harald . . . . . . . . . . . . . . . . . . 123 

Rohde, Christine . . . . . . . . . . . . . . 110, 158 

Rohrich, Rod . . . . . . . . . . . . . . . . . . . . 166 

Rosales, Roberto S. . . . . . . . . . . . . . . . . . 97 

Rose, Victoria . . . . . . . . . . . . . . . . . . . . 167 

Rosenberg, Zehava . . . . . . . . . . . . . . . . 129 

Rosenwasser, Melvin P. . . . . . . . . . . . . 134 

Rosson, Gedge D. . . . . . . . . . . . . . . . . . 139 

Roussalis, John . . . . . . . . . . . . . . . . 98, 113 

Rowe, David . . . . . . . . . . . . . . . . . . . . . . 99 

Russell, Stephen M. . . . . . . . . . . . . . . . 129 

S. Forootan, Kamal . . . . . . . . . . . . . . . . 119 

Saadeh, Pierre Boutros . . . . . . . . . . . . . 154 

Sacks, Justin Michael . . . . . . . . . . . . . . 171 

Safa, Bauback . . . . . . . . . . . . . . . . . . . 159 

Saing, Minn . . . . . . . . . . . . . . . . . . . . . 101 

Saint-Cyr, Michel . . . . . . . . . 142, 166, 183 

Sakellarides, Harilaos . . . . . . . . . . 100, 114 

Salgado, Christopher J. . . . . . . . . . . . . 174 

Sanger, James R. . . . . . . . . . . . . . . 99, 125 

Sassu, Paolo . . . . . . . . . . . . . . . . . 148, 151 

Sato, Kazuki . . . . . . . . . . . . . . . . . . . . . 106 

Sauerbier, Michael . . . . . . . . . . . . . . . . 106 

Schaefer, Dirk J. . . . . . . . . . . . . . . . . . . 171 

Schaller, Hans-Eberhard . . . . . . . . . . . . 123 

Scheufler, Oliver . . . . . . . . . . . . . . . . . . 171 

Schlosshauer, Burkhard . . . . . . . . . . . . 123 

Schnaar, Ronald . . . . . . . . . . . . . . . . . . 135 

Schramm, J. Mark . . . . . . . . . . . . . . . . 107 

Schweitzer, Mark . . . . . . . . . . . . . . . . . 129 

Schwentker, Ann . . . . . . . . . . . . . . . . . 119 

Segura, Roberto P. . . . . . . . . . . . . . . . . 139 

Selber, Jesse C. . . . . . . . . . . . . . . . 141, 143 

Sengezer, Mustafa . . . . . . . . 158, 165, 167 

Serletti, Joseph M. . . . . . . . . . . . . . . . . 141 

Serra-Hsu, Frederick James . . . . . . . . . . 89 

Shepard, Brandon . . . . . . . . . . . . . . . . 130 

Shin, Alexander Y. . . . . . . . . . . . . . . . . 104 

Shin, Hae W. . . . . . . . . . . . . . . . . . . . . 126 

Shlitner, Tzvi . . . . . . . . . . . . . . . . . . . . 127 

Siddiqui, Aamir . . . . . . . . . . . . . . . . . . . 96 

Siebert, John W . . . . . . . . . . . . . . . . . . 154 

Siemionow, Maria . . . 138, 139, 161, 162, 163, 169, 174 

Singh, Gurminder . . . . . . . . . . . . . . . . . 175 

Singh, Navin K. . . . . . . . . . . . . . . 140, 157 

Singh, Sunil P . . . . . . . . . . . . . . . . . . . 154 

Sinis, Nektarios . . . . . . . . . . . . . . . . . . . 123 

Slater, Robert R. . . . . . . . . . . . . . . . . . . 105 

Smith, Douglas H. . . . . . . . . . . . . . . . . 133 

Smith, Thomas L. . . . . . . . . . . . . . 180, 181 

Sobky, Kareem . . . . . . . . . . . . . . . . . . . . 90 

Sonnad, Seema . . . . . . . . . . . . . . . . . . 143 

Sorenson, Eric J. . . . . . . . . . 121, 122, 123 

Soslowsky, Louis J. . . . . . . . . . . . . . . . . . 92 

Sotereanos, Dean G. . . . . . . . . . . . . 95, 103 

Sparkes, Gerald . . . . . . . . . . . . . . . . . . . . 95 

Spears, Julie . . . . . . . . . . . . . . . . . . 98, 113 

Spector, Jason . . . . . . . . . . . . . . . . . . . 154 

Spiegel, Aldona J. . . . . . . . . . . . . 143, 145 

Spinner, Robert J. 120, 121, 122, 123, 128 

Stamler, Jonathan S. . . . . . . . . . . . . . . 180 

Stanley, John K. . . . . . . . . . . . . . . . 90, 112 

Steck, Jerome K. . . . . . . . . . . . . . . . . . 125 

Stephenson, Linda L. . . . . . . . . . . . . . . 173 

Sterbank, PA-C, Patrick T . . . . . . . 100, 115 

Strome, Marshall . . . . . . . . . . . . . . . . . 179 

Suchy, Hans . . . . . . . . . . . . . . . . . . . . . 172 

Sullivan, Lawrence G. . . . . . . . . . . . . . . . 93 

Swafford, Albert R. . . . . . . . . . . . . . . . . 104 

Sørensen, Hanne Birke . . . . . . . . . . . . .168 

Tai, Chau Y. . . . . . . . . . . . . . . . . . . . . . . . . 136 

Tai, Hao-Chi . . . . . . . . . . . . . . . . . . . . . . . 156 

Takayama, Shinichiro . . . . . . . . . . . . . . . . . 106 

Tang, Yueh-Bih . . . . . . . . . . . . . . . . . 156, 179 

Tannemaat, Martijn R. . . . . . . . . . . . . . . . . 116 

Tay, Shian Chao . . . . . . . . . . . . . . . . . . 87, 88 

Teng, hsiang wei . . . . . . . . . . . . . . . . . . 87, 88 

Teplitz, Glenn Alan . . . . . . . . . . . . . . . . . . . 89 

Terzis, Julia K. . . . . . . . . . . . . . . . . . . . . . . 151 

Thomas, Kenneth . . . . . . . . . . . . . . . . . . . . 90 

Tiwari, Pankaj . . . . . . . . . . . . . . . . . . . . . . 175 

Toft, Gete . . . . . . . . . . . . . . . . . . . . . . . . . 168 

Tomita, Kazunari . . . . . . . . . . . . . . 87, 88, 106 

Tong, Alice Y. . . . . . . . . . . . . . . 121, 131, 135 

Torres, Luciano Ruiz . . . . . . . . . . . . . . . . . 166 

Trigg, Stephen D. . . . . . . . . . . . . . . . . . . . 108 

Tsao, C.K. . . . . . . . . . . . . . . . . . . . . . 155, 165 

Tukiainen, Erkki . . . . . . . . . . . . . . . . . . . . . 151 

Tung, Thomas H. . . . . . . . . 121, 131, 135, 136 

Turegun, Murat . . . . . . . . . . . . . . . . . . . . . 158 

Unadkat, Jignesh . . . . . . . . . . . . . . . . . . . . 171 

Unal, Sakir . . . . . . . . . . . . . . . . . . . . . 163, 174 

Van Dam, G.M. . . . . . . . . . . . . . . . . . . . . . 133 

Van Den Berg, R.J. . . . . . . . . . . . . . . . . . . 123 

Van Dijk, J.G. . . . . . . . . . . . . . . . . . . . 118, 119 

Van Landuyt, Koenraad . . . . . . . . . . . . . . . 145 

Vanderpoorten, V. . . . . . . . . . . . . . . . 177, 178 

Vandevoort, Marc . . . . . . . . . . . 144, 177, 178 

Vasconez, HC . . . . . . . . . . . . . . . . . . . . . . 102 

Vega, Stephen J. . . . . . . . . . . . . . . . . . . . . 143 

Vela, Luis . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 

Verhaagen, Joost . . . . . . . . . . . . . . . . . . . . 116 

Vermeulen, Pieter . . . . . . . . . . . . . . . . . . . . .144 

Vivek, Prashant . . . . . . . . . . . . . . . . . . . . . 179 

Vleggeert-Lankamp, Carmen L.A.M. . . . . . 123 

Von Gregory, Henning . . . . . . . . . . . . . . . . 150 

Vranckx, Jan Jeroen . . . . . . . . . 144, 177, 178 

Wagner, Janice D. . . . . . . . . . . . . . . . . . . . 180 

Walker, Francis O. . . . . . . . . . . . . . . . . . . . 126 

Wallace, Christopher Glenn . . . . . . . . . . . . 169 

Walsh, Sarah K. . . . . . . . . . . . . . . . . . 134, 136 

Wang, Huan . . . . . . . . . . . . . . . . . . . 121, 122 

Wang, Wei Z. . . . . . . . . . . . . . . . . . . . . . . 173 

Warren, Stephen M . . . . . . . . . . . . . . 157, 162 

Waters, Peter M. . . . . . . . . . . . . . . . . . . . . . 94 

Watkins, Barry . . . . . . . . . . . . . . . . . . . . . . . 93 

Watson, Stewart J. . . . . . . . . . . . . . 88, 90, 112 

Watt, Suzanne E. . . . . . . . . . . . . . . . . . . . . 180 

Wei, F. C. . . . . . 148, 155, 164, 169, 170, 176 

Weiser, Rob W. . . . . . . . . . . . . . . . 89, 95, 103 

Weiss, Jerry . . . . . . . . . . . . . . . . . . . . . . . . 149 

Wendt, David J. . . . . . . . . . . . . . . . . . . . . . 171 

Whitlock, Elizabeth L. . . . . . . . . . . . . . . . . 130 

Wiesler, Ethan R. . . . . . . . . . . . . . . . . . . . . 126 

Williams, Christopher G. . . . . . . . . . . . . . . 140 

Windebank, Anthony J. . . . . . . . 121, 122, 123 

Winograd, Jonathan M. . . . . . . . . . . . . . . . 122 

Wolf, Jennifer Moriatis . . . . . . . . . . . . . . . . 90 

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Wong, Andrew S. . . . . . . . . . . . . . . . . . . . . 108 

Wongworawat, Montri D. . . . . . . . . . . 93, 107 

Wood, Benjamin . . . . . . . . . . . . . . . . . . . . 179 

Wu, Liza C. . . . . . . . . . . . . . . . . . . . . . . . . 142 

Wu, Ren-Chin . . . . . . . . . . . . . . . . . . . . . . 169 

Wurapa, Raymond K. . . . . . . . . . . . . . . . . . 96 

Xu, Qing Gui . . . . . . . . . . . . . . . . . . . . . . . 120 

Yafe, Batia . . . . . . . . . . . . . . . . . . . . . . . . . 183 

Yan, Yuhui . . . . . . . . . . . . . . . . . . . . . . . . . . 99 

Yan, Ji-Geng . . . . . . . . . . . . . . . . . . . . . . . 125 

Yang, Hsiang-Chen . . . . . . . . . . . . . . . . . . 169 

Yang, Johnson C. . . . . . . . . . . . . . . . . . . . 178 

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Yao, Yong . . . . . . . . . . . . . . . . . . . . . . . . . 183 

Yasui, Koji . . . . . . . . . . . . . . . . . . . . . . . . . 180 

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Yazici, Ilker . . . . . . . . . . . . . . . . . . . . 138, 139 

Yen, Chia-Hung . . . . . . . . . . . . . . . . . . . . . 169 

Yin, Jir-Wen . . . . . . . . . . . . . . . . . . . . . . . .177 

Zager, Eric L. . . . . . . . . . . . . . 133 

Zamboni, William A. . . . . . . . . 173 

Zaretski, Arik . . . . . . . . . . . . . . 149 

Zenn, Michael R. . . . . . . . . . . 180 

Zgonis, Miltiadis H. . . . . . . . . . . 92 

Zhang, Jun . . . . . . . . . . . . . . . 133 

Zhang, Lin-Ling . . . . . . . . 99, 125 

Zins, James . . . . . . . . . . . . . . . 162 

Zochodne, Douglas . . . . . 120, 136 

Zor, Fatih . . . . . . . . 158, 165, 167 

Zumiotti, Arnaldo Valdir . . . . . 166

AAHS Concurrent Scientific Paper Session 1A 

In-vivo 3-D Distal Radioulnar Joint Arthrokinematic Analysis During Resisted Active Pronation and Supination 


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 forearms 

were obtained while grasping vertical posts of a custom jig, maintaining a neutral forearm position. Scanning was then performed in three loading conditions: 

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 displacement 

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 supination 

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 evaluating 

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 subjected 

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 control 

(p=.044). No other significant differences were found by the Tekscan methodology. There was no significant difference found between neutral and supinated 

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 distal 

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 disease. 

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 tested 

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 examinations 

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 detecting 

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 interposition. 

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 “clicking” 

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 radiographs. 

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 nonlocking 

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 specimens 

were divided into 3 groups (A, B, and C) with similar bone densities based on dexascans. A completely unstable extra-articular fracture pattern was creating 

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, representing 

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

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 extraarticular 

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 significant 

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 system 

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 inclination, 

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 dominance 

DRF's. Anatomic reduction was maintained. Wrist ROM was compared to the contralateral side, at 12 weeks: dorsiflexion 77%, volarflexion 66 %, pronation 

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 significant 

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 surgical 

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 history 

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 disease 

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 recurrent 

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 interphalangeal 

(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 0.58mg 

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 extension) 

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

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 cellularity 

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 demonstrated 

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

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 failure 

(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, whereas 

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 difficult 

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 flexor 

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

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 designated 

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 experimental 

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 reinserted 

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 distally, 

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 treatment. 

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 anesthesia 

(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, necessitating 

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 general 

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 


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 purpose 

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 advancement 

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 extension. 

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 distal 

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 technique 

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; protective 

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 adjusted 

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 pronation/supination 

was supervised weekly by the therapist within the allowable arc of elbow extension/flexion. At 6 weeks transition was begun between the protected 

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 identify 

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

AAHS Concurrent Scientific Paper Session 2A 

The Cause of Carpal Tunnel Syndrome? 

Institution where the work was prepared: University of Louisville, School of Public Health 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 elevated 

in wrist postures of flexion and extension and in those patients with CTS. Classic symptoms of CTS include night waking with pain, tingling and numbness. 

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 populations 

of Americans compared to Japanese. In this report we first present a summary of the literature showing these associations. We then distill the literature 

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 mechanism, 

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 chronic 

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 included 

individuals with proven nerve dysfunction experiencing pain > 3 months. Diagnosis was established by history, physical examination, electrodiagnostic studies 

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 determined 

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 setting. 

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 ambulatory 

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 exclusively 

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 operating 

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 ambulatory 

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 compromise. 

The following study was a cadaver study defining the anatomic landmarks of compression of the median nerve in pronator syndrome. 20 fresh cadaver 

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 pronator, 

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 especially 

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 section 

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 twenty-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 complication 

rate was

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: Pendotenon) and duration dependent. 

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 


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 earlier 

studies have demonstrated clinical efficacy of ECTR but early return to activity has not been clearly documented. The purpose of the study was to compare 

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 preoperatively 

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 electrical 

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 modified 

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 differences 

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 guidance 

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 orthopedic surgery 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 neurovascularly 

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 disagreement 

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 practice 

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 iatrogenic 

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-dislocations 

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 reimbursements 

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 better 

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

Traumatic Thumb Reconstruction by Index Pollicization 


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, referring 

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 perforator 

flaps harvested in the forearm and based on perforator vessels from the radial, cubital and posterior interosseous artery. In the absence of a preoperative 

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 associated 

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 cooling 

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 perfused 

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 transplanted 

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 indirect 

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 relative 

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 translation 

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, respectively. 

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 


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 rehydrated 

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 radiographic 

evidence of severe arthritis before surgery. Pain, grip and pinch (tip and key) strength, stability and range of motion were measured pre- and post-operatively. 

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 interpostiional 

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 strenghening 

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 


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 complications. 

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 questionnaire. 

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 instability 

(2). No correlation between the use of bone graft or type of fixation and nonunion rate was noted. There was a correlation between inflammatory arthritis 

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 respectively. 

The average pain score improved to 0.7. Radiographic progression of scaphotrapezialtrapezoid (STT) arthritis was noted in 47 cases, and metcarpaophalangeal 

(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 progression 

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 arthrodesis, 

and many methods of performing that procedure have been described. More recently, new implants have been developed that offer an alternative treatment. 

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 according 

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 exception, 

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 biologically 

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 better 

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 fluoroscopic 

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

Nerve Ending Distribution in Human Radiocarpal Ligaments: a Fluorescent Immunohistochemical Study 


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) ligaments. 

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 palmar 

radiocarpal ligaments. There were no significant differences related to gender, age or side studied. There is a statistically significant difference in the number 

of nerve endings in the DRC ligament and all three palmar radiocarpal ligaments(p

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 alternative 

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 (p0.2> 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 (

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 extremity 

reconstruction. 

Methods: 

A review of patients who underwent upper extremity reconstruction with a radial forearm flap was conducted. Records were analyzed for type of reconstruction 

(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 secondary 

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 presentation, 

but may have profound sequelae. To date, management is poorly defined in the literature. We recommend prompt surgical management to avoid devastating 

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 follow-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 number 

of available imaging techniques can assist in pre-operative localization and diagnosis. Due to the close proximity of the ulnar nerve and potential for lifethreatening 

hemorrhage, we support operative treatment in all cases. Repair or ligation should be performed in all patients to minimize the risks of compressive 

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 postoperatively 

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 mechanism 

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%) compared 

to 3/29 patients treated without RT (10%). All who received brachytherapy and 14/23 (61%) treated with external beam irradiation alone had complications. 

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, mechanism 

and severity of injury, presence of concomitant trauma, total ischemic time, intra-operative blood loss, hemodynamic instability and signs of distal perfusion. 

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 malrotation, 

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 during 

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 presented 

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 mechanical 

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 evidence 

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 digitorum 

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 pullout 

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 contracture 

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 scoring 

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

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 nonpainful 

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-tender, 

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 vascular 

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 musculoskeletal 

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 original 

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 radiographic 

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 fasciotomy 

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 regarding 

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, respectively, 

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 functioning, 

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 superimposed 

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 iatrogenic 

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 muscle 

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 


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 earlier 

studies have demonstrated clinical efficacy of ECTR but early return to activity has not been clearly documented. The purpose of the study was to compare 

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 preoperatively 

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 electrical 

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 modified 

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 differences 

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 setting. 

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 ambulatory 

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 exclusively 

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 operating 

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 ambulatory 

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 adjuvant 

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 GFPpositive 

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 biologically 

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 reliable 

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 experiences. 

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 harvested 

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 buccal 

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 responded 

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 glutamatergic 

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 contains 

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 assessment 

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, deltoid, 

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

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 myelogram, 

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 population. 

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, conforming 

to axonotmesis of C5 and C6 spinal nerves with good spontaneous recovery. Predictors for poor outcome were identified using a two-step hierarchical 

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 performing 

needle elecromyography of the biceps muscle. The results can be used in routine practice to identify OBPI infants with severe lesions who may benefit 

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 present 

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 intercostals 

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 


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, weakness, 

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, average 

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 signal 

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 pathologically 

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 improving 

sensitivity will also be evaluated. 

Outcome Measures in Brachial Plexus Reconstruction 


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 measured 

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 number 

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 isometric 

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 generated 

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 forceps 

(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 sections 

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 counted 

from the lumbar spinal cord and L5 DRG. 

Results: 

Both short and long crush produced regenerative sprouting, with myelinated axon densities significantly (p

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 immunosuppression. 

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 randomized 

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 signaling 

pathways to identify mature, myelinating Schwann cells, and the caspase-3 mediated cell death pathway. Histomorphometry with electron microscopy further 

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 analysis 

also shows high level of Caspase-3 expression. Cold preserved allografts provide the most powerful stimulus for Schwann cell migration, while costimulatory 

blockade preserved donor Schwann cells and minimized migration. Mice treated with Fk506 had increased level of caspase-3 expression than those treated 

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 


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 transcutaneously 

stimulated at the cubital fossa. In group B, CMAP for evaluation of ulnar nerve motor recovery was recorded by placing subcutaneous needle electrode 

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 stimulation 

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 amplitude 

and area increased. Those parameters, except for latency, returned to preoperative level in 12 weeks. SEP of the median nerve was recorded preoperatively 

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 


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 median 

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 radial 

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 continues 

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 functional 

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 neurons. 

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 histological 

assessments of gastrocnemius muscle are done at days 7 and 21. Additional experimental groups, in which the tibial nerve underwent repair after transplantation, 

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 neuromuscular 

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 analysis. 

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 


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 innervate 

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 regeneration 

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 development 

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 sublimis 

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 median 

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 functional 

regeneration was assessed by means of the grasping test. Further examination was performed with histological analysis (S-100, PAM, Nissl), electrophysiological 

recordings, and weighing of the flexor digitorum sublimis muscle. After 12 postoperative months, functional regeneration was seen only in three animals 

of group 3 which reached about 10 % of that of the non-operated control animals (group I), however all autologous grafted animals demonstrated a partial 

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 copolymerized 

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 innervated 

muscle, and electrophysiological parameters of the nerve were evaluated. The observed changes in nerve fibre morphology were used to calculate predicted 

values of the electrophysiological parameters. We attribute differences between measured and predicted electrophysiological parameter values to compensatory 

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 


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 plantar 

tunnels since they are also potential sites of nerve compression. Additionally we hypothesized that decompression surgery, including a release of the superficial 

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 decompression 

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 decompression, 

and significantly decreased pressure in most positions in the medial and lateral plantar tunnels with decompression. Septum excision led to additional 

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 plantar 

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 sciatic 

nerves from both groups were harvested after perfusion using glutaraldehyde. Neural Fixation: The aorta was cannulated and perfused. The tissue was subjected 

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 dramatic. 

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 woollike 

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, axonal 

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 symptoms 

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 denervation 

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 complications. 

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 encompasses 

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 document 

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

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 endto-end 

neurorraphy. Five consecutive patients presented with forehead (3 patients) and dorsum of the foot (2 patients) pain. The first three patients had traumatic 

(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

The Cystic Transverse Limb of the Articular Branch: A Pathognomonic Sign for Peroneal Intraneural Ganglion 

Cysts at the Superior Tibiofibular Joint 


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 peroneal 

peroneal intraneural ganglion cysts was stereotypic; they were tubular whereas the extraneural were globular. The “tail sign” was 100% sensitive for identifying 

joint connections but could not distinguish between intra and extraneural ganglion cysts. The “transverse limb” sign [cystic material within the articular 

branch traversing the anterior fibula] was present in all cases of intraneural ganglia and none of the extraneural ganglia. The “signet ring” sign [the eccentric 

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 blinded 

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 distinction 

between peroneal intraneural and extraneural ganglion cysts (“transverse limb” and “signet ring” signs) at the superior tibiofibular joint with accuracy 

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 regeneration. 

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 muscle 

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 functional 

recovery (“sensory protection”). We are investigating the molecular changes accompanying sensory protection. Our previous studies showed that sensory protection 

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 distal 

nerve stump (immediate motor repair group). The contralateral unoperated tibial nerve and tibial nerves from naïve animals were used as controls. We analyzed 

brain-derived neurotrophic factor (BDNF), nerve growth factor (NGF) neurotrophin-3 (NT-3), glial cell line-derived neurotrophic factor (GDNF) and ciliary 

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 starting 

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 significantly 

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 electrophysiologically 

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 tibial 

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 embryonic 

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 software 

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 measurement 

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 addition 

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 completely 

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 stereology 

techniques will augment our understanding of nerve regeneration. 

130

Induction of Regional Collateral Sprouting Following Muscle Denervation 


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, published 

works report that collateral sprouting can be induced directly by denervated muscle. The current study evaluates the necessary conditions for the denervated 

masseter muscle to induce collateral axonal sprouting from branches of the facial nerve. We hypothesize that the chemotactic stimuli from denervated 

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, transection, 

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 confirmed 

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 measurements 

of ocular and vibrissial function are suboptimal, involving exposure of the cranium and the application of a piece of dental cement from which several 

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 maintained 

for months. The use of a biocompatible implant largely eliminates the tissue reaction at the skin interface, and decreases infection risk. The device permits 

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 examination. 

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 regarding 

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 


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 clinical 

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, positively 

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 functionality 

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 bioluminescence 

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 activity 

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 transplanted 

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 distal 

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 distal 

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 situation 

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 guidance 

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 accessible, 

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 transected 

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 without 

a circumferential collagen nerve protector, NeuraWrapTM. After ten weeks of healing, in vivo motor and sensory recovery was tested with extensor postural 

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 existed 

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

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 regeneration 

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 proteoglycans 

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 


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 elements 

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 regenerating 

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 sensory 

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 architecture 

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 characteristics 

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

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 somatization 

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 scalene 

muscles followed by response of the supraspinatus, rhomboids, deltoids, ECRL, and ERCB as a result of increased endoneural pressure >40 mm/hg in median/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 muscles 

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 muscle 

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 lateral 

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 fashion. 

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 


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 immunosupression 

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 gastrocnemius 

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 proximal 

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 preganglionic 

root avulsion injuries. Nerve root avulsion due to traction may occur at birth or from trauma. After brachial plexus injury, enhanced motor sprouting 

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 function. 

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 formation 

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 developed 

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 


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 allogenic 

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 sciatic 

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 gastrocnemius 

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 epineural 

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 


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 tunnel, 

the medial plantar, lateral plantar, and calcaneal nerves in their respective tunnels, and excision of the inter-tunnel septum. For patients with an associated 

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 = normal, 

10 = most severely impaired). Outcomes were also assessed by patient satisfaction and their own estimate of residual pain and/or numbness. Mean follow-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

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 autologous 

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 preoperative 

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 operative 

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 multidetectorrow 

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 intraoperative 

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 perforator 

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 dominant 

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 prospectively 

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 cardiovascular 

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 reconstruction 

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 complication 

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 abdominal 

contour. There was a trend toward SIEA patients having less postoperative pain than ms-TRAM patients. There was a statistically significant difference 

(p

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 reliability, 

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? 


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 nonsmokers, 

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 examination 

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 vessels 

are plugged in different vascular options and the decision making is still to be done during the operative procedure itself. The incidence of extra anastomoses 

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 bilateral 

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 scars. 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 multidetector 

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 operative 

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 epigastric 

perforator (DIEP) flap. 


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 illustrating 

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 immediate 

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-innervated 

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 reconstruction. 

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 radiation. 

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 complications. 

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 reconstruction 

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 deformities. 

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 performed 

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 dominant 

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 participate 

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 hospitalization 

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 public 

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 congenital 

absence of the digits and to develop an algorithm which directly predicts which microsurgical toe-to-hand transfers will provide the best hand function. 


78 toe transfers have been performed in 65 children for congenital anomalies of the hand, classified by the Swanson system as transverse deficiencies or symbrachydactyly 

(32); radial longitudinal deficiencies (5); cleft hand (9) and congenital constriction ring syndrome (17). Preoperative X-rays and photographs were analyzed to determine 

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 finger 

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 assessment 

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 monofilament 

(SWM) tests. Pinch power of the reconstructed digits as well as subjective pain and discomfort was also evaluated. Statistical analysis was used to compare 

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

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. 


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 fibula 

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, neurolysis 

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 function. 

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 


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 extremely 

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. 


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 


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 quality 

of life outcome instruments (HRQL): 1) McCabe cold sensitivity severity scale, 2) McGill pain scale, 3) Levine symptom and function scale and 4) WFU symptom 

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 symptomatic 

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 investigates 

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 lymphedematous 

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 incisions, 

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 factors 

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 (p0.05). 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

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 present 

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 standardized 

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 indicating 

reasonably good facial functioning (100 means perfect), which was better compared to recovered Bell's palsy patients after mime therapy (54.9; p

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 experience 

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 fracture 

(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 symmetric 

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 placement 

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 esthetic 

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 manifesting 

severe mandibular hypoplasia may also present with severe soft tissue deficiency. In these cases, mandibular DO alone will not be sufficient to restore appropriate 

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 performed 

subsequent to the completion of D0. The primary diagnoses of these patients were: bilateral craniofacial microsomia (3), unilateral craniofacial microsomia 

(2), Goldenhaar syndrome (1), Nager syndrome (1) and Treacher Collins (1). The free flaps utilized were the parascapular fasciocutaneous (10), parascapular 

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 compromise 

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 dehiscence, 

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. 


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 infection 

or wound dehiscence. Fiberscope examination and flow-metry at postoperation 3 months confirmed the maintenance of an adequate nasal meatus without 

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 


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 girder 

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 system” 

as a refinement of the facial buttress system for vascularized skeletal reconstruction of the midface. 


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 equally 

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 conservative 

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 selected 

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 reimplantation 

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 successfully 

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 additional 

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% success 

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 


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 fasciocutaneous 

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 common 

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 contralateral 

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 appearance 

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 treatment 

such as “Fix and Flap” within 72 hours post trauma. All patients were reviewed retrospectively with the following questions: 1. How realistic is the “golden 

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? 


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 questionaire 

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 outcome 

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 consequence 

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 favorably 

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 relation 

to the type of bony fixation. Of the 38 patients studied, twenty underwent external fixation of the tibial fracture, and eighteen had intramedullary rodding. 

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 coverage, 

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 present 

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 reconstruction. 

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 retrospectively. 

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 muscle 

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 without 

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

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 tendon 

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 surgical 

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 tendon 

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 undergone 

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 proximal 

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 chemotherapy 

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 without 

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. 


From January 2002 to December 2003. Fifty patients of head and neck cancer underwent a total 50 fibula osteocutaneous free flap for mandibular reconstruction. 

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 postoperatively. 

For each patients, the range of maximal voluntary ankle motion (inversion, eversion, flexion and extension) in each leg. If there was>20% difference, 

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

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 


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 isotransplantation 

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, masseter 

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 inflammatory 

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 demonstrated 

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 components 

of the composite allografts. Viability of tongue was confirmed by pink color, bleeding after puncture and histology. H+E staining determined the presence 

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 


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 associated 

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 


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 cadavers 

using posterior-coronal approach. For coronal-posterior approach, a posterior midline vertical incision from scalp hairline to the vertex of the scalp was performed 

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 respectively. 

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 transplantation. 

Donor/Recipient Compatibility and Morphological Outcomes of Face Transplantation: a Cadaver Study 


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 transplantation 

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 parameters 

to evaluate donor/recipient compatibility has been defined. It has been shown that, when an appropriate face is chosen, the bony structure of the underlying 

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 formerly 

achieved operational tolerance in fully MHC mismatched rat hemifacial allotransplantation model under low dose of cyclosporine-A (CsA) monotherapy without 

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-specific 

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 acceptance 

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 


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. 


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 trigeminal 

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 immunesupression. 

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) intraperitoneally 

(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 osteomyocutaneous 

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 macrochimerism 

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 compensate 

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 movement 

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). 


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 simulated 

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-innervation. 

4 months later, the animals were subjected to electrophysiological tests (Fig. II), sacrificed, and the nerves and muscles were taken for histological examination. 

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 interrupting 

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 coaptation, 

hyaluronic acid film sheath is administered. Group III: Following the coaptation, VEGF gene therapy is performed. Group IV: Both the VGEF gene therapy 

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 histopathologically. 

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

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 radiography 

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 perforator 

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 secondly, 

to establish a new comprehensive system of classifying the vascular branching patterns of the ALT perforator complex. 


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 components 

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 peroneal 

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: microdissected 

thin anterolateral thigh perforator flap, tensor fasciae latae perforator flap, deep inferior epigastric artery perforator flap, and thoracodorsal artery perforator 

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 average 

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 somatosensory 

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 resonance 

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 viability 

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 discussion 

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 urethroplasty 

was performed in all patients using buccal mucosa, except three when a Mitrofanoff channel had been created previously. Penile prosthesis, either semirigid 

(7) or inflatable (8) was implanted, in two cases after puberty. Cylinders were covered with vascular prostheses that imitate tunica albuginea and additionally 

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, neither 

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 alternative 

for phalloplasty that enables neophallic size as in adults. 

Lymph Node Transfer for Treating Mild to Moderate Lymphoedama 


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 experience 

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 glucose 

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 (Comgroup, 

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 survived 

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 


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% purity 

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 cardiac 

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 (p0.05). Transplant survival: Onset 

of rejection was significantly delayed by IJ-FDS administration (p

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 utilizing 

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. 


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 antialpha-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 examined 

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 (p100 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 represents 

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 diameter), 

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 directions 

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 connective 

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 3dimensional 

constructs via their intact microvasculature. Here we investigated whether vascularized neo-livers could be generated with differentiated progenitor 

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 proliferation 

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 sustainability 

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 generating 

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 viability/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 prefabricated 

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 specialized 

or complex the tissue to be replaced is. The ideal situation would involve the prefabrication of an almost identical structure and then free tissue transfer 

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 formation 

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 different 

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 ligand 

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 upregulated 

in response to hypoxia, and, paradoxically, also by hyperoxia. Small interference RNA (siRNA) interferes with gene expression by inhibiting translation 

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 intraperitoneal 

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 interval 

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 animals 

injected with a nonsilencing siRNA complexed with PEI. VEGF 164 and 120 protein levels were calculated based on a percentage of their respective positive 

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 administration, 

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 prolonged 

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 phenomenon”. 

Muscle is the one tissue most susceptible to ischemia and begins to undergo irreversible changes after 6 hours at room temperature. 


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 procedures 

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 procedure 

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 significant 

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 therapy 

can be employed in the postoperative period. 

Efficacy of Intravenous and Intraosseous Donor Bone Marrow Transplantation in Chimerism Induction on 

Vascularized Skin Allograft Transplants 


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 immunsuppression 

is required procedure in routine use of VSA in clinical practice. We have investigated effect of 7-day protocol of ·‚-TCR and CsA therapy augmented 

with donor bone marrow transplantation (BMT) on chimerism induction and extension of VSA survival. 


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

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 reperfusion 

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 


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 Dentistry 

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 outcome 

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 complication 

rate. Nonetheless, effective wound management yields satisfactory to excellent post-operative outcomes. Pre-operative radiation therapy remains a beneficial 

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 


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 morbidity, 

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 evaluated. 

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 infection, 

soft tissue abnormalities and hypertrophic scarring were minimal. Donor site complications were more pronounced with revisional surgeries for a cavovarus 

deformity and valgus deformity necessary in two patients. Functional outcomes related to occlusion, diet and physical activity were found to be acceptable 

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 simultaneous 

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, keratinized 

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 


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. 


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 sphincter 

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 dramatically 

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 reconstruction 

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 preserve 

one vocal cord, and thus speech, in cases were current surgical treatment usually consists of total laryngectomy. 


We treated 70 patients after a hemilaryngectomy with trachea prefabrication. The surgical technique and sequence of these two-stage procedures was substantially 

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 hemilaryngectomy 

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 territory. 

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. 


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 radial 

forearm fascia flap prelaminated with ear cartilage. Vascular induction (prefabrication) of the thick ear cartilage was required in a first stage before the laminated 

free flap transfer into the tracheal defect. Seventeen patients were treated with a one-stage procedure with bucal mucosa grafts laminated on a forearm 

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 fascial 

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 temporary 

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 postsurgical 

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 



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. 


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 reconstruction 

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 functional 

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 interposition 

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 complication. 

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 cancer 

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 performed 

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 barium 

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 maintained 

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 regardless 

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 pedicled 

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 preoperative 

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 surgical 

defects in the head and neck. 

Comparison Between Jejunum and Ileocolon Flaps in Terms of the Risk of Food Aspiration After Voice Reconstruction 


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 effective 

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 


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 studying 

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 depolarization-induced 

constrictions to 50 mM KCl were significantly attenuated at 23°C as compared to 37°C in primate digital arteries (p

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. 


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 

Veterinary Medicine, 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. 


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 control. 

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

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 cutaneous 

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 latissimus 

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 inferior 

one. Then, the vascular and nervous subsegmental bundles penetrating the corresponding muscular groups are observed. The neurovascular subsegmental bundles 

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 thoracodorsal 

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 sensory 

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 inferior 

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 majority 

of the latissimus muscle in situ, (5) maintenance of the dorsal thoracic silhouette, (6) potential for neurotization and sensory/functional muscle reconstruction 

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 cutaneous 

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 dissected, 

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 external 

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 lateral 

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 within 

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 cutaneous 

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: reliability, 

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 another 

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 produced 

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 diabetes 

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 population 

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 treated 

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. 

183

AAHS ASPN ASRM - 2013 Annual Meeting - American Association ...

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