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Local blood flow monitoring by means of the hydrogen clearance technique
VASCULAR
DISORDERS
(incl. MONITORING)
AND SOFT TISSUE COVERAGE
VASCULAR DISORDERS (incl. MONITORING) AND SOFT TISSUE COVERAGE Local blood flow monitoring clearance technique
by means of the hydrogen
H. G. Machens, P. Mailaender,
B. Rieck, A. Berger
Department of Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Germany
The hydrogen clearance technique (HCT) allows quantitative measurementsof local blood flow (LBF) in ml/min/lOO g tissue. Although this technique has been commonly employed in different fields of medicine, especially in neurology, the HCT has seldom been used in plastic surgery. We report a case of a 46-year-old male who was admitted to our hospital with claudication of the ulnar side of the right hand. Symptoms started 6 months earlier when the patient had suffered blunt trauma to the ulnar side of the right wrist. Preoperative angiography demonstrated occlusion of the ulnar artery with insufficient blood supply for the 4th and 5th digits. Skin LBF was 12.6-14.0 ml/min/lOO g and 13.5-16.8 ml/min/ 100 g, respectively, measured by the HCT (monitoring device by Ameda@/Switzerland). Skin LBF of the 1st and 2nd digit showed significantly higher values: 52.6-54.5 ml/min/lOO g* and 53.8-56.3 ml/min/lOO g*, respectively. Following revascularization by an autologous vein-graft, postoperative angiography revealed a patent ulnar artery with adequate perfusion of digits 4 and 5. Skin LBF, measured on the 6th postoperative day, was significantly altered: 47.6-49.5 ml/min/lOO g* and 50.2-53.7 ml/min/lOO g*, respectively. Claudication had disappeared promptly. We believe that the HCT is a valuable method for monitoring postoperative blood flow following digital revascularization. *: P s 0.01
The deep volar compartment of the forearm-does exist? D. M. McCarthy,
it really
J. Herndon, J. Towers, D. Sotearnos
Musculoskeletal Research Center, Medical Center, Pittsburgh, USA
University
of Pittsburgh
The decompression of both a superficial and deep compartment in the forearm has been suggestedby a number of authors when treating compartment syndromes of the volar forearm. It has also been noted that the most marked ischaemia in Volkmann’s contracture involves the deeper muscles of the forearm, in particular the flexor digitorum profundus and the flexor pollicis longus. The aim of this study was to identify and delineate a deep volar compartment. The interosseous membranes of 15 cadaveric forearms were exposed through a dorsal approach. A 5% dyed gelatin solution was then injected through the membrane and allowed to accumulate on the volar side of the membrane. The limbs were then placed in a freezer at - 10°C for 24 hours and then sectioned transversely and longitudinally. The distribution of the dye was assessed.A further five forearms had radio-opaque dye injected in a similar manner and had immediate CT scan evaluation. Another ten specimens had gadolinium and dye
5
combined and again injected into the forearms in like manner. All had immediate MRI evaluation. Following MRI, the limbs were stored for twenty four hours in a freezer and then sectioned transversely. The distribution of the dye was compared to the MRI images. In all forearms there was a well-delineated distribution of the dye or contrast agent in the deeper part of the forearm. The CT and MRI scans displayed a similar pattern of contrast distribution. In the radiological assessment,there was free flow of contrast into the carpal tunnel, but not into the hand. Our results suggest a selective accumulation of dye and contrast in the deeper muscles of the forearm. This selective infiltration may explain why these muscles are more extensively involved in Volkmann’s contracture of the forearm. Our study highlights the importance of adequate decompression of these muscles in all casesof compartment syndrome of the forearm. The fact that dye entered the carpal tunnel refutes the concept that the carpal tunnel is a distinct compartment.
New pathogenetic interpretations and proposals for treatment of acute functional acrosyndromes S. Russo, L. Messore, G. Quarto, G. Coca, E. Rispoli University Degli Studi Di Napoli, Federico II, Napoli, Italia
The aetiology of peripheral angiopathy is disputed and this controversy extends to treatment. The authors in the light of haemodynamic and physiological studies on the microcirculation dispute the classical division of peripheral angiopathies into functional and non-functional. We consider that all peripheral angiopathies are at first functional and only later become non-functional. The early functional phase could consist of persisting spasm of the precapillary sphincter leading to opening of arteriovenous shunts. There is then a progressive increase in capillary units provided with A-V shunts and later there is arterial metaplasia of A-V shunts and of the draining venule. During the functional stage it is possible to interfere with this mechanism by modulation of sympathetic activity. The earlier this sympathetic modulation is applied, the greater the chance of functional recovery and the prevention of irreversible A-V arterial metaplasia. The authors discuss different pathogenetic possibilities for this sympathetic imbalance, including a change in the number of peripheral receptors, a change in the excitability of the normal receptors, abnormal release of catecholamines, or excitation of surrounding abnormal receptors. Potential central causes are also discussed. On the basis of the above hypotheseswe report our experience of the treatment of twelve patients with unilateral or bilateral upper limb angiopathies during the acute phase by modulation of sympathetic response. All the patients showed a prompt recovery from angiospasm with improvement of cutaneous trophism, temperature and dermal flux demonstrated not only by clinical examination but also by doppler examination, thermography and TPBS. Five patients had a permanent recovery over two years and in the others with more advanced disease we observed some trophic improvement and relief from pain but without persisting improvement of digital blood flow.
DISORDERS
(incl. MONITORING)
AND SOFT TISSUE COVERAGE
VASCULAR DISORDERS (incl. MONITORING) AND SOFT TISSUE COVERAGE Local blood flow monitoring clearance technique
by means of the hydrogen
H. G. Machens, P. Mailaender,
B. Rieck, A. Berger
Department of Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Germany
The hydrogen clearance technique (HCT) allows quantitative measurementsof local blood flow (LBF) in ml/min/lOO g tissue. Although this technique has been commonly employed in different fields of medicine, especially in neurology, the HCT has seldom been used in plastic surgery. We report a case of a 46-year-old male who was admitted to our hospital with claudication of the ulnar side of the right hand. Symptoms started 6 months earlier when the patient had suffered blunt trauma to the ulnar side of the right wrist. Preoperative angiography demonstrated occlusion of the ulnar artery with insufficient blood supply for the 4th and 5th digits. Skin LBF was 12.6-14.0 ml/min/lOO g and 13.5-16.8 ml/min/ 100 g, respectively, measured by the HCT (monitoring device by Ameda@/Switzerland). Skin LBF of the 1st and 2nd digit showed significantly higher values: 52.6-54.5 ml/min/lOO g* and 53.8-56.3 ml/min/lOO g*, respectively. Following revascularization by an autologous vein-graft, postoperative angiography revealed a patent ulnar artery with adequate perfusion of digits 4 and 5. Skin LBF, measured on the 6th postoperative day, was significantly altered: 47.6-49.5 ml/min/lOO g* and 50.2-53.7 ml/min/lOO g*, respectively. Claudication had disappeared promptly. We believe that the HCT is a valuable method for monitoring postoperative blood flow following digital revascularization. *: P s 0.01
The deep volar compartment of the forearm-does exist? D. M. McCarthy,
it really
J. Herndon, J. Towers, D. Sotearnos
Musculoskeletal Research Center, Medical Center, Pittsburgh, USA
University
of Pittsburgh
The decompression of both a superficial and deep compartment in the forearm has been suggestedby a number of authors when treating compartment syndromes of the volar forearm. It has also been noted that the most marked ischaemia in Volkmann’s contracture involves the deeper muscles of the forearm, in particular the flexor digitorum profundus and the flexor pollicis longus. The aim of this study was to identify and delineate a deep volar compartment. The interosseous membranes of 15 cadaveric forearms were exposed through a dorsal approach. A 5% dyed gelatin solution was then injected through the membrane and allowed to accumulate on the volar side of the membrane. The limbs were then placed in a freezer at - 10°C for 24 hours and then sectioned transversely and longitudinally. The distribution of the dye was assessed.A further five forearms had radio-opaque dye injected in a similar manner and had immediate CT scan evaluation. Another ten specimens had gadolinium and dye
5
combined and again injected into the forearms in like manner. All had immediate MRI evaluation. Following MRI, the limbs were stored for twenty four hours in a freezer and then sectioned transversely. The distribution of the dye was compared to the MRI images. In all forearms there was a well-delineated distribution of the dye or contrast agent in the deeper part of the forearm. The CT and MRI scans displayed a similar pattern of contrast distribution. In the radiological assessment,there was free flow of contrast into the carpal tunnel, but not into the hand. Our results suggest a selective accumulation of dye and contrast in the deeper muscles of the forearm. This selective infiltration may explain why these muscles are more extensively involved in Volkmann’s contracture of the forearm. Our study highlights the importance of adequate decompression of these muscles in all casesof compartment syndrome of the forearm. The fact that dye entered the carpal tunnel refutes the concept that the carpal tunnel is a distinct compartment.
New pathogenetic interpretations and proposals for treatment of acute functional acrosyndromes S. Russo, L. Messore, G. Quarto, G. Coca, E. Rispoli University Degli Studi Di Napoli, Federico II, Napoli, Italia
The aetiology of peripheral angiopathy is disputed and this controversy extends to treatment. The authors in the light of haemodynamic and physiological studies on the microcirculation dispute the classical division of peripheral angiopathies into functional and non-functional. We consider that all peripheral angiopathies are at first functional and only later become non-functional. The early functional phase could consist of persisting spasm of the precapillary sphincter leading to opening of arteriovenous shunts. There is then a progressive increase in capillary units provided with A-V shunts and later there is arterial metaplasia of A-V shunts and of the draining venule. During the functional stage it is possible to interfere with this mechanism by modulation of sympathetic activity. The earlier this sympathetic modulation is applied, the greater the chance of functional recovery and the prevention of irreversible A-V arterial metaplasia. The authors discuss different pathogenetic possibilities for this sympathetic imbalance, including a change in the number of peripheral receptors, a change in the excitability of the normal receptors, abnormal release of catecholamines, or excitation of surrounding abnormal receptors. Potential central causes are also discussed. On the basis of the above hypotheseswe report our experience of the treatment of twelve patients with unilateral or bilateral upper limb angiopathies during the acute phase by modulation of sympathetic response. All the patients showed a prompt recovery from angiospasm with improvement of cutaneous trophism, temperature and dermal flux demonstrated not only by clinical examination but also by doppler examination, thermography and TPBS. Five patients had a permanent recovery over two years and in the others with more advanced disease we observed some trophic improvement and relief from pain but without persisting improvement of digital blood flow.