Large skeletal defects of the upper extremity pose a serious clinical problem with potentially deleterious effects on both function and viability of the limb. Recent advances in the microsurgical techniques involved in free vascularized bone transfers for complex limb injuries have dramatically improved limb salvage and musculoskeletal reconstruction. This study evaluates the clinical and radiographic results of 18 patients who underwent reconstruction of large defects of the long bones of the upper extremity with free vascularized fibular bone grafts. Mean patient age was 27 years (7-43 years) and mean follow-up was 4 years (1-10 years). The results confirm the value of vascularized fibular grafts for bridging large bone defects in the upper extremity.

Shoulder stabilization is of utmost importance in upper extremity reanimation following paralysis from devastating injuries. Although secondary procedures such as tendon and muscle transfers have been used, they never achieve a functional recovery comparable to that following successful reinnervation of the supraspinatus, deltoid, teres minor, and infraspinatus muscles. Early restoration of suprascapular and axillary nerve function through timely brachial plexus reconstruction offers a good opportunity to restore shoulder-joint stability, adequate shoulder abduction, and external rotation function. Overall, in our series, 79% of patients achieved good and excellent shoulder abduction (muscle grade, +3 or more), and 55% of patients achieved good or excellent shoulder external rotation after reinnervation of the suprascapular nerve. The best results were seen when direct neurotization of the suprascapular nerve from the distal spinal accessory nerve or neurotization by the C5 root was carried out. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction and external rotation function.

A comparison of outcomes based on a scoring system for assessments, described by Rosén and Lundborg, after sharp complete laceration of median and/or ulnar nerves at various levels in the forearm was carried out. There were 66 males (90.4%) and 7 females (9.6%), with a mean age of 31 years (range: 14-62 years). The patients were categorized into three groups according to the type of nerve injury. The median nerve was injured in 25 cases (group M, 34.3%), the ulnar in 27 (group U, 36.9%), and both the nerves in 21 (group MU, 28.8%). The demographic data of the patients and the mechanism of injury were recorded. We also examined the employment status at the time of the injury and we estimated the percentage of patients who returned to their work after trauma. In all cases, a primary epineural repair was performed. Concomitant injuries were repaired in the same setting. The mean period of time between injury and surgery was 5.3 hours (range: 2-120 hours). A rehabilitation protocol and a reeducation program were followed in all cases. The mean follow-up was 3 years (range: 2-6 years), with more distal injuries having a shorter follow-up period. The total score was 2.71 in group M (range: 0.79-2.99) and 2.63 in group U (range: 0.63-3), with no significant differences observed. There was a significant difference between these two groups and group MU (total score 2.03, range: 0.49-2.76, P = 0.02). Up to the last follow-up, 61 patients (83.5%) had returned to their previous work. The Rosén-Lundborg model can be a useful and simple tool for the evaluation of the functional outcome after nerve injury and repair temporally reflecting the processes of regeneration and reinnervation.

Bone grafts are an important part of orthopaedic surgeon's armamentarium. Despite well-established bone-grafting techniques, large bone defects still represent a challenge. Efforts have therefore been made to develop osteoconductive, osteoinductive, and osteogenic bone-replacement systems. The long-term clinical goal in bone tissue engineering is to reconstruct bony tissue in an anatomically functional three-dimensional morphology. Current bone tissue engineering strategies take into account that bone is known for its ability to regenerate following injury, and for its intrinsic capability to re-establish a complex hierarchical structure during regeneration. Although the tissue engineering of bone for the reconstruction of small to moderate sized bone defects technically feasible, the reconstruction of large defects remains a daunting challenge. The essential steps towards optimized clinical application of tissue-engineered bone are dependent upon recent advances in the area of neovascularization of the engineered construct. Despite these recent advances, however, a gap from bench to bedside remains; this may ultimately be bridged by a closer collaboration between basic scientists and reconstructive surgeons. The aim of this review is to introduce the basic principles of tissue engineering of bone, outline the relevant bone physiology, and discuss the recent concepts for the induction of vascularization in engineered bone tissue.

The brachial plexus is a complex network of nerves which extends from the neck to the axilla and which supplies motor, sensory, and sympathetic fibers to the upper extremity. Generally it is formed by the union of the ventral primary rami of the spinal nerves, C5-C8 and T1, the so-called "roots" of the brachial plexus. The goal here is to examine the neural architecture of the brachial plexus. The most constant arrangement of nerve fibers will be delineated, and then the predominant variations in neural architecture will be defined, particularly the prefixed and postfixed plexus, as well as the microanatomy and anatomy of the major terminal branches of the plexus. Multiple tracts connect many parts of the nervous system, and multiple ascending and descending tracts connect the peripheral nervous system (PNS) and lower spinal centers with the brain. This reflects that the nervous system is able to extract different pieces of sensory information from its surroundings and encode them separately, and that it is able to control specific aspects of motor behavior using different sets of neurons. Examination of the major sensory or motor pathways reveals a highly and tightly organized nervous system. In particular, at each of many levels, we see fairly exact maps of the world within the brain. In an effort to understand the functional neuroanatomy of the brachial plexus, this paper will focus briefly on the nervous connections of the nerves of the upper extremity with the brain. The goal here is to better understand "what the brain sees" after nerve injury and repair.

This study was designed to quantitatively assess long-term end-to-side neurorrhaphy in rabbits. The cut right ulnar nerve was repaired and sutured to the median nerve, in which a perineurial window was created in an end-to-side fashion 3 cm above the elbow joint. Both the extent of the reinnervation and the integrity of the intact donor nerve were evaluated in 36 rabbits randomly treated with fresh or delayed nerve repair. Evaluations included motor nerve conduction velocity (MNCV), dry muscle weight (DMW), and histological examinations at 9 and 12 months postoperatively. The recovery rates of MNCV were 90.1% and 92.8% for the ulnar nerve, and 95.7% and 96.8% for the median nerve, compared to intact contralateral nerves at 9 and 12 months, respectively. MNCV was not detectable for the ulnar nerve in control animals, while it was normal for the median nerve. Recoveries of flexor carpi ulnaris dry muscle weight of about 90.7% and 94.5% were observed at 9 and 12 months postoperatively, respectively. However, muscle mass measurements revealed a recovery of only 31.3% and 27% for control groups at 9 and 12 months postoperatively. The differences between experimental groups and control groups were statistically significant (P < 0.01). Neurofilament and silver stains showed numerous sprouting axons originating from the median nerve to the ulnar nerve. The results indicate that end-to-side neurorrhaphy could induce axonal sprouting from the main nerve trunk of upper limbs in rabbits, leading to useful functional recovery.

The healing and regeneration capacity of the injured tissues in childhood, adolescence, and adult life differs significantly. As a result, the prognosis of compound injuries of the upper limb in different age groups varies; therefore, the decision making and management of these cases should be age-specific. This article presents a series of 32 patients aged 1.5-14 years, with compound injuries of the upper limb that have been treated in our hospital during the period of the last 6 years. Ten of the above cases involved major vascular lesions that required revascularization or replantation. The injuries were classified according to the SATT (Severity, Anatomy, Topography, Type) classification system. This study shows that the outcome of compound upper limb injuries is age-related, while the SATT classification system is a valuable tool in the decision making process. Further research should be undertaken to determine age group-specific indications for the management of compound upper limb injuries, based on the SATT classification system.

The aim of this study was to assess the effectiveness of reinnervation using end-to-side neurorrhaphy in the upper extremity of the rabbit. The cut right ulnar nerve was repaired and sutured to the side of the median nerve about 3 cm above the elbow joint. The extent of reinnervation was quantitatively evaluated, as well as the integrity of the intact donor nerve in 36 rabbits randomly treated with fresh or delayed nerve repair with or without perineurotomy. Evaluations included nerve conduction velocity (NCV) of both the ulnar and medial nerves, dry muscle weight, and histologic examination (neurofilament stain and morphometric assessment) at 3 and 6 months postoperatively. NCV recovery rates were 79% and 87% for the ulnar nerve, and 89% and 94% for the median nerve compared to contralateral intact nerves, at 3 and 6 months, respectively. Flexor carpi ulnaris muscle mass measurements revealed a recovery in dry muscle weight of about 81% and 88% at 3 and 6 months, respectively, compared to the intact contralateral flexor carpi ulnaris. Histologic studies with neurofilament staining reveal numerous axonal sprouts at the distal end of the median nerve, indicative of myelinated axonal regeneration. Morphometric analysis demonstrated no difference between fresh and delayed repairs. These results indicate that in the upper extremity of rabbits, end-to-side neurorrhaphy permits axonal regeneration from the intact donor nerve, and is associated with satisfactory recovery. The effect of the procedure on the donor nerve was negligible.