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Background: Bone marrow stimulation techniques in cartilage repair such as drilling are limited by the formation of fibrous to hyaline-like repair tissue. It has been suggested such techniques can be enhanced by covering the defect with scaffolds. We present an innovative approach using a polyglycolic acid (PGA)-hyaluronan scaffold with platelet-rich-plasma (PRP) in drilling.Questions/purposes: We asked whether (1) PRP immersed in a cell-free PGA-hyaluronan scaffold improves patient-reported 1-year outcomes for the Knee injury and Osteoarthritis Score (KOOS), and (2) implantation of the scaffold in combination with bone marrow stimulation leads to the formation of hyaline-like cartilage repair tissue.Patients and Methods: We reviewed 52 patients who had arthroscopic implantation of the PGA-hyaluronan scaffold immersed with PRP in articular cartilage defects of the knee pretreated with Pridie drilling. Patients were assessed by KOOS. At 9 months followup, histologic staining was performed in specimens obtained from five patients to assess the repair tissue quality.Results: The KOOS subscores improved for pain (55 to 91), symptoms (57 to 88), activities of daily living (69 to 86), sports and recreation (36 to 70), and quality of life (38 to 73). The histologic evaluation showed a homogeneous hyaline-like cartilage repair tissue.Conclusions: The cell-free PGA-hyaluronan scaffold combined with PRP leads to cartilage repair and improved patient-reported outcomes (KOOS) during 12 months of followup. Histologic sections showed morphologic features of hyaline-like repair tissue. Long-term followup is needed to determine if the cartilage repair tissue is durable.Level Of Evidence: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

During recent decades, the concept of surgical treatment of malignant bone and soft tissue sarcomas has evolved, with the aim of preserving limb function. In this paper we report a case of metatarsal reconstruction by means of serratus and rib free flap after excision of a synovial sarcoma located in the dorsal aspect of the midfoot. Five years after the operation, the patient was free from recurrence and recovered full foot function. Amputation has been widely used in the past and this procedure still remains a valuable option when limb salvage is not possible. Nevertheless, in selected cases, reconstruction by means of composite free flaps may be successfully used for limb preservation in the treatment of malignant foot tumors after surgical excision.

The aim of our study was to analyze the clinical outcome after repair of cartilage defects of the knee with subchondral drilling and resorbable polymer-based implants immersed with autologous platelet-rich plasma (PRP). Fifty-two patients with focal chondral defects were treated with subchondral drilling, followed by covering with a polyglycolic acid - hyaluronan (PGA-HA) implant (chondrotissue®) immersed with autologous PRP. At 5-year follow-up, patients' situation was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and compared to the pre-operative situation. The KOOS showed clinically meaningful and significant (p < 0.05) improvement in all subcategories compared to baseline. Subgroup analysis showed that there were no differences in the clinical outcome regarding defect size and localization as well as degenerative condition of the knee. Cartilage repair was complete in 20 out of 21 patients at 4-year follow-up as shown by magnetic resonance observation of cartilage repair tissue (MOCART) scoring. Covering of focal cartilage defects with the PGA-HA implant and PRP after bone marrow stimulation leads to a lasting improvement of the patients' situation.

Purpose: The aim of our study was to analyse the clinical and histological outcome after the treatment of focal cartilage defects in non-degenerative and degenerative knees with bone marrow stimulation and subsequent covering with a cell-free resorbable polyglycolic acid-hyaluronan (PGA-HA) implant immersed with autologous platelet-rich plasma (PRP)., Methods: Fifty-two patients (mean age 44 years) with focal chondral defects in radiologically confirmed non-degenerative or degenerative knees were subjected to subchondral drilling arthroscopically. Subsequently, defects were covered with the PGA-HA implant immersed with autologous PRP. At 2-year follow-up, the patients' situation was assessed using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and compared to the pre-operative situation and 3-12-month follow-up. Biopsies (n = 4) were harvested at 18-24 months after implantation and were analysed by histology and collagen type II immune staining., Results: At 1- and 2-year follow-up, the KOOS showed clinically meaningful and significant (p < 0.05) improvement in all subcategories compared to baseline and to 3-month follow-up. There were no differences in KOOS data obtained after 2 years compared to 1 year after the treatment. Histological analysis of the biopsy tissue showed hyaline-like to hyaline cartilage repair tissue that was rich in cells with a chondrocyte morphology, proteoglycans and type II collagen., Conclusions: Covering of focal cartilage defects with the PGA-HA implant and PRP after bone marrow stimulation improves the patients' situation and has the potential to regenerate hyaline-like cartilage., Level of Evidence: Case series, Level IV.

The reconstruction of loss of substance due to trauma or oncological excision may have relevant functional and aesthetic implications. We report our experience in twenty-one cases of propeller flaps for the treatment of loss of substance of the upper and lower limbs. The etiology of defect was tumor excision in nine cases, trauma in seven cases, surgical wound complications in four cases, and chronic osteomyelitis in one case. Clinical results were favorable in most cases and eighteen flaps survived. We observed an overall complication rate of 33% with four cases of superficial epidermolysis that spontaneously healed and three cases of partial flap loss ranging from 10 to 50% that required surgical revision by means of skin graft (two cases) or ALT free flap (one case). Propeller flap harvesting requires great care and experience, and potential complications may occur even in expert hands. When indicated by the characteristic of the defect, these flaps can be a useful surgical option for the treatment of loss of substance of upper and lower limbs.

Several methods are used to evaluate the functional outcome of tumour resections and reconstructions in the lower limb. However, one of their most common limitations is that they are specifically developed to evaluate only oncological patients. We introduced the Lower Limb Core Scale (LLCS) to overcome this limitation. The aim of this study was to evaluate the functional and subjective results in the lower limb and to evaluate the use of the LLCS. We conducted a retrospective cohort study using various tools to investigate the outcomes. The results of the LLCS were correlated with the results of other functional tests. A total of 44 patients were included in the study. None of the demographic variables correlated with the functional or health-related quality of life (QoL) scores except for gender, whereby male patients had an increased functional score. The correlation between LLCS and other scores was positive (r (2) = 0.77). The satisfactory QoL scores, and functional outcomes scores indicated the LLCS to be a reliable option for general and specific evaluation of lower limb reconstructions. We suggest using the LLCS for comparisons of oncological reconstructions with lower limb reconstructions in different disciplines.

Y-shaped vein conduits enriched with fresh skeletal muscle fibers were used to bridge a concomitant ulnar and median nerve transection with substance loss in rats. The proximal limb of the Y-chamber was sutured to the proximal ulnar nerve, while the two distal limbs were sutured to ulnar and median distal nerve stumps. Eight months after surgery, median nerve functional recovery was evaluated by means of the grasping test, and nerve fiber regeneration in both repaired nerves was assessed by means of design-based histomorphometry. Results showed that nerve fibers regenerated along both severed nerve trunks, and in the median nerve led to a recovery corresponding to 58% of normal nerve function. Quantitative analysis showed no significant morphological differences between myelinated nerve fibers regenerated along the two distal nerves except for the number of fibers, which was higher in the median nerve. Notably, the total number of regenerated nerve fibers in the two distal nerves was 4-fold the normal fiber number in the ulnar nerve. Besides their interest in relation to the long-lasting debate about the topographic specificity of nerve regeneration, the results of this study show an effective way to repair, in the rat experimental model, two transected nerve trunks innervating agonistic muscles in the case that the proximal stump of only one nerve is preserved., ((c) 2004 Wiley-Liss, Inc.)

While it has been shown that terminolateral (end-to-side) neurorrhaphy leads to successful functional motor reinnervation of the peripheral territories belonging to the severed nerve, data on the morphology of terminolateral sprouting and on the voluntary control of the motor function restored by terminolateral neurorrhaphy are still partial. In this study, the severed rat median nerve was sutured in an end-to-side fashion to the intact ulnar nerve. The progression of recovery of the flexion of the fingers was assessed by means of the grasping test. Seven months after surgery, the rats were sacrificed, and morphologic and morphometric analysis was performed on the regenerated median nerve and on the donor ulnar nerve. Results of the functional assessment showed that voluntary motor control of the muscles innervated by the median nerve was partially and progressively recovered by terminolateral neurorrhaphy, with a mean strength in the flexion of the fingers that reached about 20 percent of normal before sacrifice. Morphologic and morphometric analysis showed that nerve-fiber regeneration occurred in all repaired median nerves. Signs of nerve fiber atrophy were detected in the ulnar nerve distal to the point of suture, suggesting the possible occurrence of secondary damage to the donor nerve after terminolateral neurorrhaphy that should be taken into consideration in a clinical perspective.

The authors report their experience with short- and medium-term microdiskectomy for the treatment of lumbar disc herniation. It is based on 760 operations performed between 1985 and July 1999: expulsed hernias and those of large size with intense pain symptoms and/or neurologic deficit were treated. During the same period of time, the authors used enzymatic and percutaneous nucleolysis according to Onik for smaller hernias. The incidence of satisfactory results was high (90.1%), in agreement with the results published in the literature. There was a low incidence of complications (4.6%), and of these 2.8% had a benign spontaneous evolution; 1% was prevented during surgery, 0.5% was prevented with subsequent surgery, while only 0.2% was the cause of definitive failure. Unsatisfactory results were constituted by the sequelae of complications (1 discitis, 4 liquoral cysts, 1 error in level not diagnosed intraoperatively), stenosis of the lateral recess not diagnosed pre- or intraoperatively, and thus not treated; in 6.1% of cases there was no plausible justification. The microsurgical technique above all reduces the duration of hospitalization (5 days on the average, but with 91% of cases dismissed on day 3), and allows for a rapid return to work activity (after 63 days for patients who are not employees, but with a return after 20 days in 95% of cases).