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The last 15 years have seen a growing interest regarding a technique for nerve repair named end-to-side coaptation. Since 2000, we have carried out experimental studies on end-to-side nerve repair as well as employed this technique to a series of selected clinical cases. Here we report on the results of this experience.For experimental studies, we have used the model represented by median nerve repair by end-to-side coaptation either on the ulnar (agonistic) or the radial (antagonistic) nerve. For time course assessment of median nerve functional recovery we used the grasping test, a test which permits to assess voluntary control of muscle function. Repaired nerves were processed for resin embedding to allow nerve fibre stereology and electron microscopy. Results showed that, in either experimental group, end-to-side-repaired median nerves were repopulated by axons regenerating from ulnar and radial donor nerves, respectively. Moreover, contrary to previously published data, our results showed that voluntary motor control of the muscles innervated by the median nerve was progressively recovered also when the antagonistic radial nerve was the donor nerve.As regards our clinical experience, results were not so positive. We have treated by end-to-side coaptation patients with both sensory (n = 7, collateral digital nerves) and mixed (n = 8, plexus level) nerve lesions. Results were good, as in other series, in sensory nerves whilst they were very difficult to investigate in mixed nerves at the plexus level.Take together, these results suggest that clinical employment of end-to-side coaptation should still be considered at the moment as the ultima ratio in cases in which no other repair technique can be attempted. Yet, it is clear that more basic research is needed to explain the reasons for the different results between laboratory animal and humans and, especially, to find out how to ameliorate the outcome of end-to-side nerve repair by adequate treatment and rehabilitation.

Surgical treatment of equinus deformity in cerebral palsy can be carried out successfully by Achilles tendon lengthening and gastrocnemius aponeurosis lengthening. From 1993 to 1998, we performed 59 operations in 37 cerebral palsied patients with equinus deformity using Z-lengthening in 30 cases and a modified Baker's procedure in 29 cases. The operations, associated with other hip and knee procedures in 65% of patients, were followed by postoperative use of casts and by a 12-month intensive kinesitherapeutic protocol. On preoperative evaluation, besides pattern deformity and the condition of proximal joints, we considered also age, clinical diagnosis, nature of tone and muscle strength. In most cases, the retrospective analysis showed the correction of deformity and a functional improvement. We observed 9 recurrences in six of the younger patients without relationship with topographic pattern of cerebral palsy. Overcorrection of equinus deformity occurred in one diplegic child who had phasic hypertonia and low muscle strength. We believe that the evaluation of patients, the preoperative planning and the effective kinesitherapeutic program are necessary to reduce the risk of complications related to surgery.

Heterotopic ossification is a post-surgery compli- cation occasionally observed in patients with in- fantile cerebral palsy. In the majority of the cases such lesions are found at the hip after surgery on the skeleton and the soft tissues. At our Institute in the last five years, this com- plication has been observed four times, in 39 pa- tients, who underwent mainly soft tissue releas- es because of flexion and adduction contracture of the hip, In these cases, as in a further patient with myelomeningocele, the periarticular heterotopic ossification appeared in the hip after tenotomy of the ilio-psoas at the lesser tronchater associat- ed to other surgical procedures. Conversely, no cases of ossification have been found after tenotomy of the adductors or the gracilis or selective tenotomy of the psoas at the pelvic brim. The exact causes of this complication are still un- clear, but after an analysis of the literature and patient history it can be hypothesised that it may be related to the surgical procedures carried out.