For decades the treatment of chronic posttraumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopedic surgery. “Sterilization” of the osteomyelitic site, that is radical debridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the debrided area was closed with skin grafts, which were removed in a further stage, when the infection was ceased; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time requiring several-stage treatment.

We performed a retrospective study on 9 patients treated for chronic osteomyelitis of the upper limb (6 forearm – 3 arm) by means of free fibula vascularized bone graft, between 1992 and 2003 (7 male 2 female). All patients had been more than 2 previous surgical attempt with conventional treatment (sterilization and bone graft). In most of them (7 cases) a two-stage treatment was performed (resection and sterilization, eventually with muscle transfer, in the first stage and bone transfer in the second one); in other 3 cases a one-stage treatment was performed. Two cases required a composite tissue transfer with a skin pad to cover the exposure. The length of bone defect after extensive resection of necrotic bone from septic pseudoarthrosis ranged from 5 cm to 12 cm.

In all cases there was no evidence of infection recurrence in the follow-up period. The mean period to obtain radiographic bone union was 4.1 months (range 2.5–6 months). In 2 cases secondary procedures have been carried out due to an aseptic non union in one site of synthesis (cruentation and compression plate). Functional results were always satisfactory although in the forearm a complete range of motion has never been achieved (plurioperated patients with DRUJ problems).

Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius, ulna and humerus of sufficient length to reconstruct most skeletal defects. The vascularized fibular graft is indicated in patients where conventional bone grafting has failed or large bone defects, exceeding 5 cm, are observed. The application of microsurgical fibular transfers for reconstruction of the extremities allows repair of bone and soft-tissue defects when shortening is not possible with good functional results.

Aims: Multiple nerve repair by means of a Y-shaped nerve guide represents a good model for studying the specificity of peripheral nerve fiber regeneration. Here we have employed this model for investigating the specificity of axonal regeneration in mixed nerves of the rat forelimb model. Specificity of nerve regeneration can be defined as the ability of the nerve fibers of a peripheral nerve, after a lesion. Tree types of specificity on nerve regeneration has been postulated: “tissue specificity” (the preferential reinnervation of distal nerve tissue versus other types of tissue), topographic specificity (regenerating nerve fibers are preferentially attracted by analogous distal pathways (e.g. preferential regeneration along tibial nerve pathways by tibial nerve fibers), and end-organ specificity, which is the hypothesis that distal end-organs (muscle vs. sensory targets) specifically attracts the respective (motor vs. sensory) regenerating nerve fibers. Exists no agreement regarding the presence and features of the two last type of specificity.

Methods: The left median and ulnar nerves, in adult female rats, were transected and repaired with a 14-mm Y-shaped conduit. The proximal end of the Y-shaped conduit was sutured to the proximal stump of either the median nerve or the ulnar nerve. Ten months after surgery, rats were tested for functional recovery of each median and ulnar nerve. Quantitative morphology of regenerated myelinated nerve fibers was then carried out by the two-dimensional disector technique.

Results: Results showed that partial recovery of both median and ulnar nerve motor function was regained in all experimental groups. Performance in the grasping test was significantly lower when the ulnar nerve was used as the proximal stump. Ulnar test assessment showed no significant difference between the two Y-shaped repair groups. The number of regenerated nerve fibers was significantly higher in the median nerve irrespectively of the donor nerve, maintaining the same proportion of myelinated fibers between the two nerves (about 60% median and 40% ulnar). On the other hand, nerve fiber size and myelin thickness were significantly larger in both distal nerves when the median nerve was used as the proximal donor nerve stump. G-ratio and myelin thickness/ axon diameter ratio returned to normal values in all experimental groups.

Conlusions: These results demonstrate that combined Y-shaped-tubulization repair of median and ulnar nerves permits the functional recovery of both nerves, independently from the proximal donor nerve employed, and that tissue, and not topographic, specificity guides nerve fiber regeneration in major forelimb mixed nerves of rats.

Aims: The combination of microsurgical techniques with engineering of pseudo-nerves has recently seen an increased employment for the repair of peripheral nerve defects. Over the last ten years, we have investigated a particular type of bio-engineered nerve guide, the muscle-vein-combined tube, which is made by filling a vein with skeletal muscle. However, the basic mechanism underlying the effectiveness of this surgical technique are still unclear and yet an experimental study on its efficacy on functional recovery compared to traditional nerve autografts is still lacking in the literature. The aim of the present study was thus to fill this gap.

Methods: In rats, 10-mm-long median nerve defects were repaired using either traditional autografts or fresh muscle-vein-combined bioengineered scaffolds. Posttraumatic nerve recovery was assessed by grasping test. The samples were collected at different times after surgery: 5, 15, 30 days and 6 months. Analysis was carried out by light and electron microscopy. In addition, reverse transcription polymerase chain reaction (RT-PCR) was used to investigate the expression of mRNAs coding for glial markers as well as glial growth factor (NRG1) and its receptors (erbB2 and erbB3).

Results: Results showed that both types of nerve repair techniques led to successful axonal regeneration along the severed nerve trunk as well as to a partial recovery of the lost function as assessed by grasping test. Rats operated on by traditional nerve autografts performed better in the grasping test. Biomolecular analysis by RT-PCR demonstrated early overexpression during nerve regeneration of the gliotrophic factor NRG1 and two of its receptors: erbB2 and erbB3.

Conclusions: Our results confirmed that use of muscle-vein-combined tissue-engineered conduits is a good approach for bridging peripheral nerve defects in selected cases when traditional autografts are not employable and disclosed one of the basic biological mechanism that support the effectiveness of this surgical technique. Our experience also suggested that the rat forelimb experimental model is particularly appropriate for the study of microsurgical reconstruction of major mixed nerve trunks. Furthermore, since the forelimb model is less compromising for the animal, it should be preferred to the hindlimb model for many research purposes.

Aims: Biosynthetic scaffolds made of degradable bio-materials enriched with cultured cells holds promise for peripheral nerve repair after complex traumatic injuries. In the perspective of future transplantation applications, the aim of this study was to investigate how cultures of olfactory ensheathing cells (OECs), in particular neonatal olfactory ensheathing cells (NOBECs), grow up in vitro on degradable polymeric films made with polycap-rolactone matrices and multi-block polyesterurethane respectively. In addition, since several transplantation studies use green fluorescent protein (GFP) positive cells so that they can be easily located in the receiving tissues, the cDNA encoding for GFP was cloned in expression vector and transfected in NOBECs.

Methods: To characterize NOBECs we employed electron microscopy, immunohistochemistry, RT-PCR and western blotting analyses. Moreover the proliferative ratio of NOBECs and the ability of the cells to migrate in a three dimensional environment were evaluated under basal and experimental culture conditions. Finally, the GFP-positive NOBEC were seeded on two types of synthetic films and their behaviour was analyzed to determine cell adhesion, survival and proliferation.

Results: We examined the expression of glial markers and NRG1/ErbB system in the NOBEC cell line at RNA and protein level. Results showed that NOBECs express both glial markers (GFAP and S-100), ErbB receptors (ErbB1, ErbB2 and ErB3) and different isoforms of NRG1. NOBECs exhibited a remarkable proliferation activity and a high basal migration activity. GFP positive NOBECs showed no significant difference in their behaviour as compared to untransfected parental cells. Finally, both normal and GFP-NOBECs showed good cell adhesion, survival and proliferation properties when seeded on both films employed in this study.

Conclusion: Taken together, results of our study showed that the glial cell line has similar biochemical properties as primary cultures of OECs. Moreover, we showed that NOBECs survive, proliferate and migrate on two different types of synthetic films that were prepared in the perspective of build up nerve scaffolds. Therefore, our results indicated that the NOBECs produce growth-promoting proteins and possess regeneration-promoting capabilities that make them a potentially good transplant material to enhance axonal regeneration inside synthetic tubes used to bridge nerve lesion with substance loss.

Aims: Muscle fat degeneration and fibrosis following long time denervation is today the main cause of poor functional recovery after peripheral nerve surgery especially for reconstruction of proximally located lesions of median and ulnar nerves such as those at brachial plexus level. External electro-stimulation is actually one possible way to avoid muscular atrophy and degeneration and is frequently used in the post-operative of patients with neurological palsy. A new approach that has been proposed to prevent denervation-related muscle atrophy is sensory protection performed by direct neurotization of a denervated muscle with a branch of a sensitive nerve passing nearby. The aim of this study was to study the effectiveness of sensory protection on denervated muscles as a technique to avoid their atrophic process.

Methods: In four groups of rats (A,B,C and D), the median nerves were transected at right and left forearm. In group A,B and C, denervated muscles were “reinnervated” with a sensory nerve (sensory protection). Animals of group A was sacrificed after six months for a morphologic study of muscles. Animals of groups B and C were reinnervated after six months either keeping sensory protection (group B) or removing it (group C) and sacrificed after one year. Group D (without sensory protection) was reinnervated after six months and sacrificed after one year (control group). Muscle histology was performed on all samples. Functional comparison of different group was perfor-mend by means of the grasping test.

Results: Histological analysis showed that sensory protection led to a better muscular trophism in all experimental groups. Also the functional testing showed better performances in sensory protected animals and especially in group C (de-protected before re-innervation) compared with group B (not de-protected before re-innervation) and D (control).

Conclusions: Initial data analisys obtained in this study showed that sensory protection is effective in reducing denervation-related muscle atrophy. De-protection of the muscle before its reinnervation is also important to ameliorate post-surgical functional recovery. A new trial will be carried out with a larger number of cases in order to confirm these results which could have important applications in the clinical perspective.

Aims: the recent ten years have seen a growing interest in termino-lateral (end-to-side) neurorrhaphy; this interest mainly originates from the prospected possibility to recover the function of a damaged nerve without loosing the function of a donor nerve.

We investigated voluntary control recovery after termino-lateral neurorrhaphy in the upper limb of mixed rat nerves (median and ulnar nerves) to assess functional recovery and nerve fibers regeneration.

Methods: We made a termino-lateral neurorrhaphy between median (lesioned) and ulnar nerve (donor) on left upper limb of 24 Wistar female rats. After 6 months, functional recovery of the limb was investigated using grasping test and electrical stimulation; then, rats were sacrificed and we studied morphological changes in muscles and regenerated nerves with light microscopy and stereology.

Results: We observed a functional recovery up to 15 % ± 5% of the normal at grasping test, while electrostimulation was positive in all cases; muscle trophism was good (40 % > than denervated muscles).

On microscope median nerve presented the typical structure of a regenerated nerve; in ulnar nerve some slight signs of degeneration can be detected distally to the site of suture. At the point of suture, nerve fibers of ulnar nerve sprouts into median nerve (collateral sprouting).

Conclusions: Termino-lateral neurorrhaphy induces a collateral sprouting from the donor nerve (as described in the literature); fiber regeneration in the severed nerve leads to a recovery of voluntary functional control.

In the donor ulnar nerve distally to the suture site we found some slight signs of damage, but they do not impair motor function.

In conclusion, termino-lateral neurorrhaphy can be used to repair peripheral nerve lesions with large substance loss where other types of repair strategies cannot be attempted.

Surgical treatment of complex wounds of the lower extremities has greatly evolved in the last years, leading to a higher percentage of limb salvage and good functional recovery.

Microsurgery surely is a good weapon when facing extensive tissue losses and infections.

From 1994 to 2004, 25 patients have been treated in our department for complex traumas of the lower limb.

These cases include 4 acute complex injuries with extensive soft tissue loss (Gustilo III open fractures) which were treated with 3 Latissimus Dorsi and 1 Gracilis Muscle Flaps; 10 delayed referrals with exposed bone or bony/soft tissue loss (1 Fibula Flap for the distal femur, 1 Fibula Flap for the lower leg, 3 cases of amputation stump coverage, 2 Parascapular Flaps, 2 Gracilis Flaps, 1 Latissimus Dorsi Flap, 1 Serratus Flap with a rib, 1 Iliac Crest Flap); and 11 late reconstructions of chronic osteomyelitis: 1 distal femur infection (Double-barrel Fibula Flap), 10 infections of the middle or distal third of the lower leg (3 Fibula Flaps, 4 Latissimus Dorsi Flaps, 3 Gracilis Muscle Flaps).

In the last few years, the approach to bony tissue losses has been changing: on one hand, elongation techniques for the lower extremity give good results; on the other, microsurgery may allow a single-stage reconstruction of bone, muscle and skin defects, leading to much shorter hospitalization time, and improvement of the patients’ quality of life because of a faster recovery.

Over 90% of the flaps survived, leading to a good recovery of the patients. The two failures were due to the necrosis of a Gracilis Flap in the coverage of an amputation stump and that of a Latissimus Dorsi Flap used for an extensive soft tissue loss in a leg which subsequently had to be amputated.

In 78.5% of the cases of osteomyelitis recovery was obtained after a single operation, and in only 12.3% of the cases the flaps had to be partially revised.

In 2 cases, after the bony resection and coverage by means of a Gracilis Muscle Flap, a homolateral fibular transfer with the Ilizarov technique was performed.

The length of bone resections treated by fibular flaps was 8–12 cm (mean 9).

In amputation or amputation-like injuries of lower limbs, only in a few cases reconstructive treatment with microsurgery is encouraged, according to evaluation of lesion by Mangled Extremity Severity Score (MESS). Replantation cases may require substantial bone shortening, as consequence to seriousness of the trauma or a deliberate choice to enable primary vessel and nerve repair. Callus distraction technique by external fixation, circular or axial, is a common method for recover lengthening in these cases of replanted or revascularized extremities.

We report six cases of lower limb replantation or revascularisation, with primary bone shortening from 3 to 7 cm and secondary lengthening by callus distraction.

It was always obtained equalization of lower extremities, with successful rehabilitation of the patients and low onset of complications during treatment.

For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle.

We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed.

In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary.

In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs.

Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination).

The aetiology, pathogenesis and clinical staging of osteonecrosis of the femoral head have been the subject of considerable discussion. The same is true regarding the treatment of such conditions, which could be non-operative (shockwaves, no traction, PEMFs) or operative (conservative methods or prosthetic substitution), depending on the age of the patient and the degree of compromise of the femoral head.

During the period between 1972 and 2003 at the CTO Hospital of Turin, Italy, 54 patients underwent surgery. We used core decompression (forage biopsy) in 39 cases and in the other 15 cases free vascularised fibular grafting (microsurgical techniques). All the patients were at the initial stages of the condition (Steinberg I–IIIa), stages in which subchondral collapse had not yet occurred. Follow up average 125.6 months.

The results were estimated according to the Harris Hip Score, which allows for a score in relation to pain upon motional, functional and clinical deformity.

In light of our data, we can confirm that the advantage of the result is secondary to the appropriate use of surgical techniques in relation to the clinical staging of the pathology. We have, in fact, established a treatment protocol that calls for core decompression at stage 0 – IA and free vascularised fibular grafting at the more advanced stages that go from IB to IIIA.