PTFE patch saphenoplasty appears to be safe. Although these are early results, the technique seems potentially as effective as other barrier methods that have been investigated; in ten legs (12 per cent) recurrence was attributed to failure at the level of the PTFE patch.

Peripheral nerve injuries are common, and there is no easily available formula for successful treatment. Although primary neurorrhaphy and nerve autografts are the most effective methods of repair, several newer options are at our disposal today. Though one can help speed up the nerve regeneration process to some extent, success is hindered by additional issues such as number of coaptation sites, supply of donor nerves and the limitations of nerve substitutes. There is now considerable evidence that peripheral nerves have the potential to regenerate if an appropriate microenvironment is provided. A better understanding of the biological processes involved in nerve regeneration process and the realization that nerve grafts serve as a guide for the growing neurons led to the concept of entubulation techniques. For distances of less than 3 cms, either a nerve conduit or an autologous vein graft serves equally well as nerve graft. Seeding the conduits with cultured Schwann cells has pushed the limit of nerve regeneration through a 6 cm gap. In experimental studies with Schwann cell lined bioengineered conduits gaps as large as 8cms can be bridged. Advances in bioengineering has allowed creation of composite neural tubes lined with Schwann cells and neurotropic agents that enhances regeneration of nerve fibers, block the invasion of scar tissue and autodegrade when it is no longer required. The evolution of the concept of entubulation, the early experimentation, the present development and various types of conduits are discussed here.

BACKGROUND: The risk of a major stroke after a transient ischaemic attack (TIA) is highest in the first 3 months after the onset of symptoms. Urgent endarterectomy in appropriate cases is recommended through a fast-track one-stop assessment clinic. METHODS: Local general practitioners (GPs) were informed that a duplex scan would be guaranteed within 14 days of referral of any patient who had a recent clearly documented TIA or amaurosis fugax. Referral letters were faxed and the scan was authorized by a consultant surgeon. Those with significant disease were seen in the clinic in preparation for operation. Non-significant results were conveyed by post to the GPs with no further action. RESULTS: In the first 12 months of the service, 90 scans were performed through the fast track. In the same interval 490 non-fast-track scans were done after request by a physician (38 per cent), geriatrician (24 per cent), neurologist (14 per cent), vascular surgeon (11 per cent), ophthalmologist (8 per cent) or others (4 per cent). Thirteen (14 per cent) of 90 patients in the fast-track group had carotid endarterectomy, with a median period between referral and operation of 30 (range 20-45) days and median time between onset of symptoms and surgery of 7 (range 4-58) weeks. Endarterectomy was carried out in 12 (2 per cent) of 490 patients in the routine group with a median duration between referral and operation of 127 (range 64-184) days. CONCLUSION: A fast-track service can significantly reduce the time between referral and operation, and increase the number of endarterectomies. Urgent and appropriate referral from the GPs is vital for the service to work efficiently.

A 21-year-old man with known hereditary multiple exostoses presented with a 24-hour history of atraumatic bruising and swelling of the posterior thigh. A leaking popliteal pseudoaneurysm was diagnosed on ultrasonography and an emergency saphenous vein bypass graft procedure performed. The patient required a post-operative blood transfusion but otherwise made a full recovery. Vascular complications from osteochondromas are rare and include vessel displacement, stenosis, occlusion, arteriovenous fistulas and pseudoaneurysm formation. Pseudoaneurysms usually present as an enlarging mass behind the knee. Acute rupture of an occult popliteal pseudoaneurysm caused by a distal femoral exostosis has not been reported previously.

In irreparable C5, C6 spinal nerve and upper truncal injuries the proximal root stumps are not available for grafting, hence repair is based on nerve transfer or neurotization. Between Feb 2004 and May 2006, 23 patients with irreparable C5, C6 or upper truncal injuries of the Brachial Plexus underwent multiple nerve transfers to restore the shoulder and elbow functions. Most of them (16 patients) sustained injury following motor cycle accidents. The average denervation period was 5.3 months. Shoulder function was restored by transfer of distal part of spinal accessory nerve to suprascapular nerve, and transfer of radial nerve branch to long head of triceps to the anterior branch of axillary nerve. Elbow function was restored by transfers of ulnar and median nerve fascicles to the biceps and brachialis motor branches of musculocutaneous nerve. All patients recovered shoulder abduction and external rotation; 7 scored M4 and 16 scored M3. Range of abduction averaged 1230(range, 800-1700). Full elbow flexion was restored in all 23 patients; 15 scored M4 and 8 scored M3. Patients with excellent results could lift 5 kgs of weight. Selective nerve transfers close to the target muscle provide an early and good return of functions. There is negligible morbidity in donor nerves. These intraplexal transfers are suitable in all cases of upper brachial plexus injuries.