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Biomedical subjects

G R Brunelli

Publications and source records attributed to G R Brunelli.

At least 19 recordsLinked to original sources
PubMed1999

Restoration of walking in paraplegia by transferring the ulnar nerve to the hip: A report on the first patient.

There is no known way to make paraplegics walk when their spinal cord is completely transected. Many researchers worldwide have been developing different methods to solve this problem. We believe that transferring a sound nerve from the upper limb to the main muscles of the hip could help paraplegics to walk, although light orthotic devices would still be needed. We chose to transfer the ulnar nerve because it is the longest in the upper limb and can reach the glutei without grafts. In addition, palsy of the ulnar nerve can be repaired by classical reconstructive surgery. After many years of research in animals and after obtaining permission from the Ethical Committee of the National Health Surgery, we operated on three human beings bilaterally. The first patient is walking. Two are still recovering.

Adult↗
PubMed1999

Arterial anatomy and clinical application of the dorsoulnar flap of the thumb.

After injection of stained latex at the brachial artery, the arterial supply of the dorsal aspect of the thumb was studied by light microscopy in 25 cadavers. An artery, located on the dorsoulnar side and connecting the head of the first metacarpal with the dorsal arcade of the proximal nail fold, was found in all dissections. We report the results of the anatomic study and the clinical applications of a dorsoulnar skin flap that can be raised on its artery with a distal pedicle. Clinical experience is based on 32 flaps. In 25 cases this flap was used for distal skin loss coverage (palmar or dorsal) of the thumb as an island flap. In 7 cases it was used for reconstruction of the finger pulp (5 index and 2 middle fingers) in the form of a cross-finger flap.

Cadaver↗
PubMed1997

[Replacement operations in areas innervated by the median nerve in brachial plexus paralysis].

Brachial plexus lesions generate complex paralysis and deficient sensitivity in the concerned upper extremity. The clinical features are represented in numberless variations, and in any case several nerves will be involved. Isolated median nerve palsies can only be produced by a lesion of its single terminal branch. For this reason, any secondary surgery aiming at restoring muscle function in the median nerve area should consider the entire upper extremity as a functional unit. Using special "charts" will give a better overview and simplify the choice for the most convenient muscles to transfer.

Arm↗
PubMed1996

Thumb reconstruction.

Experience in 161 thumb reconstructions are reported. The results of pollicizations are evaluated according to function, cosmesis, and two-point discrimination. Of 49 pollicization, 32 were considered excellent, 10 very good, 5 good, and 2 fairly good. In the 16 wrap-around procedures, all showed a very good (less than 6 mm) or good (6 to 12 mm) two point discrimination. Similar results were seen after toe-to-hand transfers when careful nerve repair had been performed.

Amputation, Traumatic↗
PubMed1995

Preoperative assessment of the adult plexus patient.

Methods of assessing brachial plexus lesions are presented in relation ot the type of lesion, the severity, the prognosis, and the timing of nerve repair and reconstructive surgery. A careful physical examination of both muscles and sensory function, the sweating concordance, and the Tinel sign are considered the most important aspects of assessment which is completed by electromyography (evoked potentials), radiographs, magnetic resonance imaging, and contrast computerised axial tomography (CT scanning). Contrast-CT is considered the most reliable investigation to reveal root avulsion from the cord. An assessment chart able to show the extent and location of the lesion at a glance is included.

Adult↗
PubMed1995

Modified Steindler procedure for elbow flexion restoration.

The results of modified Steindler procedures for elbow flexion performed during the past 20 years were reviewed retrospectively. The modifications were designed to avoid the phenomenon of the patient having to make a fist in order to obtain elbow flexion (Steindler's effect). The flexor carpi ulnaris, the flexor carpi radialis, and the palmaris longus, along with a bone fragment, are transferred to the anterior aspect of the humerus. The muscles are carefully separated from the flexor digitorum superficialis, which is left in place. This avoids both flexion of the fingers and pronation. Indications are discussed, especially in brachial plexus reconstructive surgery. Steindler's procedure is indicated in upper plexus lesions (C5-C6); other transfers are more appropriate for lower plexus palsies. Results were assessed according to elbow flexion against resistance. Flexion over 120 degrees when lifting 3 kg was rated very good. Of 32 modified Steindler procedures reviewed, 18 were rated very good, 8 good, 4 fair, and 2 poor.

Bone Transplantation↗
PubMed1995

[A new surgical technique for carpal instability with scapho-lunar dislocation. (Eleven cases)].

A new operation for correcting carpal instability with scapholunate dissociation is presented. Rupture of the volar scaphoid-trapezium-trapezoid ligament (i.e. the fibrous sheath of the F.C.R.) is recognized to play a prominent role in the etiology of this instability. The scar formed in between the scaphoid and lunate bones is removed as well as that formed between scaphoid, trapezium and trapezoid. A slip of F.C.R. is passed throughout a tunnel pierced in the distal pole of the scaphoid. The slip is then sutured to the dorsolunar ridge of the distal radius with correction of both the dissociation and the scaphoid flexion. The operation is easy and quick. Eleven cases are presented with satisfactory results.

Follow-Up Studies↗
PubMed1995

Microvascular fibular grafts in skeleton reconstruction.

Extensive bone defects from any cause require large bone grafts. Such large defects usually cannot be repaired by conventional, nonvascularized cancellous grafts. Before the advent of microsurgery, many of these lesions could not be cured, and amputation was often the only solution. The bone may be transferred alone or in combination with skin or muscle or both. Idiopathic femoral head necrosis is 1 of the main indications for free microvascular (fibular) transfer. The authors propose a new classification for idiopathic femoral head necrosis. A technique that has been used for the past 14 years, on providing mechanical support and improved blood supply to the femoral head, is described. The fibula is favored for its mechanical properties and its vascular pedicle, and because it is easier to harvest.

Adult↗
PubMed1995

Microsurgical reconstruction of sensory skin.

Loss of sensory function is a severe impairment for the hand which loses a lot of its dexterity, becomes "blind" if not guided by sight and is susceptible to burns, wounds and infections. Nerve repair by sutures or grafts is the preeminent operation if the condition of the skin is good. When skin is damaged, various sensory flaps (both free microvascular and local pedicle) may be used. Island flaps from the pulp of another digit give inconsistent results. Sensory flaps from the back of the index finger to the thumb give a fair two-point discrimination. Free microvascular flaps from the pulp or the web of the hallux or from two or even three toes are safe and good operations which restore both perfect skin coverage and excellent sensory function with good two-point discrimination. The damage at the donor site is well tolerated. When previous operations have covered the digit or the hand by means of non-sensory skin, direct neurotization of this skin is possible. Research has been done in animals showing the formation of free endings inside the neurotized skin. Rehabilitation of the previously existing sensory corpuscles is even possible. Our series includes 12 island flaps from the pulp, 19 pedicle flaps from the dorsum, 17 homodigital reverse flow flaps, 38 different types of free neurovascular flaps from the foot and 3 direct sensory neurotization.

Amputation, Traumatic↗
PubMed1995

Tissue changes at different periods of ischemia.

A multidisciplinary study was done to examine the following: (a) pathophysiological changes in muscle and nerve response following different periods of normothermic and cold ischemia; (b) alterations in the release of enzymes (K, LDH), CA++, K=and lactate under these conditions; and (c) histological alterations of vessels, nerves and muscles after different periods of normothermic and cold ischemia. The results demonstrate that hypothermic ischemia greatly reduces both the leakage of enzymes, cellular damage and pathological responses. We infer that amputated parts containing muscular masses may be replanted with good prognosis for satisfactory functional results within 4-5 hours at room temperature. By reducing the temperature, the time between cooling and revascularization may be doubled. Parts without muscles may be replanted 10-12 hours after normothermic ischemia and up to 24 hours or even longer after cold ischemia.

Animals↗
PubMed1994

Different conduits in peripheral nerve surgery.

A considerable amount of research is being undertaken regarding the possibility of bridging loss of nerve substance with different guiding tubes, in order to improve functional outcome, reduce the surgical time, and reduce damage at donor nerve sites. A review of the literature and personal research allows us to state that: for short gaps, biological tubes (autologous veins) may give good results and also allow chemotactic attraction with selective arrangements of motor and sensory axons. Gaps longer than 1 cm do not allow tropism and are associated with failure to support axonal regrowth. Artificial biodegradable conduits still show results that are controversial; they may give good results provided that the material of which they are made is perfectly tolerated. Empty tubes, longer than 8-10 mm, besides being deprived of the chemotactic attraction, may collapse or be partially reabsorbed and replaced by scar. Probably in the near future biological or biodegradable tubes, containing laminin-like substances or muscle scaffold, will allow us to bridge increasingly large defects in nerves.

Humans↗
PubMed1993

Direct muscle neurotization.

The results of experimental research, as well as of a large clinical series (n = 51) of direct muscle neurotization, have been encouraging enough to warrant extending the indications for the procedure to patients in whom traditional repair by direct nerve suture or nerve graft is impossible, because of the lack of a distal nerve segment, or because of destruction of the neural portion of one or more muscle groups. Prerequisites include a satisfactory volume of muscle with sufficient vascularity and adequate postoperative joint and muscle immobilization.

Animals↗
PubMed1992

Anatomy of the extensor pollicis brevis muscle.

52 hands have been dissected to check the anatomy and function of the extensor pollicis brevis. Various abnormalities were found: absence of the E.P.B. (two), insertion on the distal phalanx (four), absence of bony insertion on the base of the first phalanx and insertion on the extensor hood (36). In ten cases (in addition to the two with absence of E.P.B.), no function was elicited by pulling the tendon which inserted upon the extensor hood.

Cadaver↗
PubMed1992

Combined second toe and partial nail transfer from the big toe by means of an exteriorized pedicle.

The hand of a three-year old girl was reconstructed by means of a bilateral second toe transplantation following traumatic amputation of all five digits. In a second operation, aimed at reconstructing the index finger, the nail apparatus of the big toe was transferred to the thumb as an "island flap" based on a pedicle from the second toe. The thumb was subsequently lengthened enabling a three-fingered hand to be obtained with only minimal functional impairment of the feet. The authors suggest an original technique allowing transfer of the second toe and of the big toe nail in only one operative stage. The technique of leaving the pedicle exteriorized during transplantation (autonomization) facilitates positioning of the nail onto the recipient site and eliminates subsequent problems of commissural retraction.

Amputation, Traumatic↗
PubMed1992

A fourth type of brachial plexus injury: middle lesion (C7).

The authors describe a fourth type of traumatic brachial plexus lesion which was found in 11% of injuries to the spinal nerve roots, trunks and cords. This lesion consists of isolated or predominant lesion of the middle elements. While high lesions are caused by shoulder trauma in a downward direction and low lesions by trauma in abduction, middle lesions are produced by trauma in an anteroposterior direction. The high incidence of this type of lesion led the authors to propose the following new classification: high lesions (C5, C6)(Duchenne-Erb); middle lesions (C7); low lesions (C8, T1) (Dejerine-Klumpke); complete lesions.

Brachial Plexus↗
PubMed1992

Reconstruction of traumatic absence of the thumb in the adult by pollicization.

Amputation of the thumb is a severe handicap. In an emergency situation, thumb amputation must be treated by means of reimplantation when possible. If reimplantation cannot be performed or fails, several methods of thumb reconstruction can be used according to various factors. These include the number of surviving fingers and the level of the thumb amputation. Pollicization is the first choice for amputations proximal to the metacarpophalangeal joint when four and even three fingers are present. It is the easiest and safest operation that supplies the best results both from the motor and sensory points of view. Pollicization can be done even in an emergency situation in selected patients. The index finger is preferred because it can be pollicized without palmar scar or tendons, vessels, or nerves crossing over. If a damaged finger is present, it is preferred to the index finger to leave one more sound finger; a damaged finger can frequently be used, because the thumb is shorter than the other fingers, and although its mobility is very important at the trapeziometacarpal joint, it is less important at the metacarpophalangeal and interphalangeal joint levels. It is preferable to take as much second metacarpal bone as necessary to place the transferred second metacarpophalangeal joint at the position of the thumb metacarpophalangeal joint so that the tendons of the index interosseous muscles can be sutured to the intrinsic muscles of the thumb. According to this concept, the distal phalanx of the transferred finger should be amputated. In this manner, the new thumb will have a normal size, only two phalanges, only one extrinsic flexor, and normal insertion of the muscles of the thumb.

Adult↗