Management of Superficial and Deep Peroneal Nerve Neuromas with Targeted Muscle Reinnervation in Nonamputees: Operative Technique and Early Outcomes.

Background: Targeted muscle reinnervation (TMR), a surgical technique developed by the senior authors that coapts proximal ends of nerves to distal motor nerves of adjacent muscles, has demonstrated efficacy in the treatment and prevention of neuroma pain. The objective of this study is to describe the surgical technique for TMR of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN) in nonamputee patients and provide data on postoperative functional outcomes. Methods: A single-institution retrospective chart review was performed between March 2018 and April 2021. Patients were de-identified and included if they were nonamputees receiving TMR for pain in the peroneal nerve distribution. Data extracted included demographic information, symptoms before operation, relevant nerve coaptation, peri-, and postoperative complications, and long-term functional outcomes. Results: Of the 19 patients reviewed, 11 patients underwent TMR of the SPN alone: eight had complete resolution of their symptoms; two indicated partial improvement in pain; and one patient had no improvement. Four patients underwent TMR of the DPN alone: two patients had complete resolution of their pain, and two patients had partial improvement with pain. Four patients underwent TMR of both the SPN/DPN: two patients had complete resolution of their symptoms, and two patients were noted to have significant improvement but had persistent pain from prior foot operations. Average follow-up time was 260 days. Conclusions: TMR is a successful technique in the management of SPN and DPN neuroma pain. Our technique revealed excellent clinical outcomes, no procedure-specific complications, and improved subjective pain reports.

Regenerative Peripheral Nerve Interface: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain.

Surgical procedures, including nerve reconstruction and end-organ muscle reinnervation, have become more prominent in the prosthetic field over the past decade. Primarily developed to increase the functionality of prosthetic limbs, these surgical procedures have also been found to reduce postamputation neuropathic pain. Today, some of these procedures are performed more frequently for the management and prevention of postamputation pain than for prosthetic fitting, indicating a significant need for effective solutions to postamputation pain. One notable emerging procedure in this context is the Regenerative Peripheral Nerve Interface (RPNI). RPNI surgery involves an operative approach that entails splitting the nerve end longitudinally into its main fascicles and implanting these fascicles within free denervated and devascularized muscle grafts. The RPNI procedure takes a proactive stance in addressing freshly cut nerve endings, facilitating painful neuroma prevention and treatment by enabling the nerve to regenerate and innervate an end organ, i.e., the free muscle graft. Retrospective studies have shown RPNI's effectiveness in alleviating postamputation pain and preventing the formation of painful neuromas. The increasing frequency of utilization of this approach has also given rise to variations in the technique. This article aims to provide a step-by-step description of the RPNI procedure, which will serve as the standardized procedure employed in an international, randomized controlled trial (ClinicalTrials.gov, NCT05009394). In this trial, RPNI is compared to two other surgical procedures for postamputation pain management, specifically, Targeted Muscle Reinnervation (TMR) and neuroma excision coupled with intra-muscular transposition and burying.

Targeted Muscle Reinnervation: Surgical Protocol for a Randomized Controlled Trial in Postamputation Pain.

Over the past decade, the field of prosthetics has witnessed significant progress, particularly in the development of surgical techniques to enhance the functionality of prosthetic limbs. Notably, novel surgical interventions have had an additional positive outcome, as individuals with amputations have reported neuropathic pain relief after undergoing such procedures. Subsequently, surgical techniques have gained increased prominence in the treatment of postamputation pain, including one such surgical advancement - targeted muscle reinnervation (TMR). TMR involves a surgical approach that reroutes severed nerves as a type of nerve transfer to "target" motor nerves and their accompanying motor end plates within nearby muscles. This technique originally aimed to create new myoelectric sites for amplified electromyography (EMG) signals to enhance prosthetic intuitive control. Subsequent work showed that TMR also could prevent the formation of painful neuromas as well as reduce postamputation neuropathic pain (e.g., Residual and Phantom Limb Pain). Indeed, multiple studies have demonstrated TMR's effectiveness in mitigating postamputation pain as well as improving prosthetic functional outcomes. However, technical variations in the procedure have been identified as it is adopted by clinics worldwide. The purpose of this article is to provide a detailed step-by-step description of the TMR procedure, serving as the foundation for an international, randomized controlled trial (ClinicalTrials.gov, NCT05009394), including nine clinics in seven countries. In this trial, TMR and two other surgical techniques for managing postamputation pain will be evaluated.

Persistent perineal sinus following proctocolectomy in the inflammatory bowel disease patient.

Prolonged perineal wound healing following proctocolectomy in patients with inflammatory bowel disease (IBD) is a frustrating result for the medical team and patients who were hoping for improved quality of life. Prolonged healing, which lasts more than 6 months following proctocolectomy, is termed persistent perineal sinus (PPS) and typically necessitates further surgical management. Healing of the PPS is difficult due to the resulting "dead space" following proctocolectomy, necessitating the need to fill the void with viable tissue in an area with anatomic constraints. Here we provide a narrative review and comprehensively address the incidence, pathogenesis, and clinical and operative management of a PPS in patients with IBD following proctocolectomy. Operative methods discussed include surgical debridement, flap closure of the perineum, omental flap closure, and gracilis muscle transposition. It is necessary to further investigate and establish a gold standard of care for these patients.

Novel mesh suture may resist bone cutting seen with wire-based sternal closures.

Objective: Sternal dehiscence is frequently associated with wire-based closures cutting through fragile bone, allowing sternal motion, separation, and infection. We investigated whether bone cutting could be limited by using a newly available mesh suture with improved force distribution. Methods: Five sternal models were closed using 8 interrupted single sternal wires, double sternal wires, braided poly(ethylene terephthalate) sutures, single-wrapped mesh sutures, or double-wrapped mesh sutures. To simulate chest-wall forces, closed sternal models were pulled apart using 1020 N of axial force applied incrementally. Double sternal wire and double-wrapped mesh suture were further compared by closing 3 new models with each material and subjecting these models to cyclic loading cycles, simulating breathing and coughing. Image analysis of needle hole size measured "bone cutting" by each closure material and sternal distraction as a function of force. Results: All models exhibited maximal separation at the xiphoid. During axial loading, needle hole size increased 7.2% in the double-wrapped mesh suture model and 9.2% in the double-wire model. Single-wrapped mesh suture, single wires, and braided poly(ethylene terephthalate) extended needle hole size by 6.7%, 47.0%, and 168.3% of original size, respectively. The double-wire model resisted sternal distraction best, separating 0.285 cm at the xiphoid. During cyclic loading, mesh suture exhibited significantly less bone cutting (P = .02) than double wire, with comparable levels of sternal separation (P = .07). Conclusions: Mesh suture may resist bone cutting seen in sternal wire closure in bone models with comparable distraction to currently used sternal closure methods.

Pushing the DIEP Envelope with ERAS: 24 Hour Discharge is Safe in Appropriately Selected Patients.

Enhanced recovery after surgery protocols have become increasingly adopted for autologous breast reconstruction, demonstrating improved quality of care and reduced hospital stays. Despite this, average length of stay remains over 3 days. We have found, in appropriately selected patients, hospital length of stay can be safely reduced to less than 48 hours. Methods: Retrospective review was performed of patients who underwent microsurgical breast reconstruction by the senior author (M.H.) from April 2019 to December 2021. Demographics, operative details, length of stay, and postoperative complications are reported to assess for safety of discharge within 48 hours, with the primary outcome measure being flap loss. Results: In total, 188 flaps were performed on 107 patients. Average age was 51.4 years (SD 10.1 years) with average BMI 26.6 kg/m2 (SD 4.8 kg/m2). Average length of stay was 1.97 days (SD 0.61 days), and 96 patients (89.7%) were discharged within 48 hours. Six flaps (3.2%) required operative takebacks. Five of the six (83.3%) takebacks occurred on postoperative days zero or one, and all five of these flaps were salvaged. There were four breast hematomas (2.1%), four breast seromas (2.1%), eight breast infections (4.3%), 13 breasts (6.9%) with wound dehiscence, four flaps (2.1%) with partial flap loss, and 24 breasts (12.8%) with mastectomy flap necrosis. One hundred fifty flaps (79.8%) had no complications. Overall success rate of flap reconstruction was 99.5%. Conclusion: Hospital discharge in 24-48 hours is safe in appropriately selected patients undergoing autologous tissue breast reconstruction.

Patient definitions of transplant success in upper extremity vascularized composite allotransplantation: A mixed-methods study.

Objective: Upper extremity vascularized composite allotransplantation is an innovative treatment option for people with upper extremity amputations. Limited patient-relevant long-term outcomes data about transplant success may impede patients' informed treatment decision-making. We assessed perceptions of what constitutes upper extremity vascularized composite allotransplantation success among individuals with upper extremity amputations. Methods: This multisite study entailed interviews and focus groups with individuals with upper extremity amputations and upper extremity vascularized composite allotransplantation candidates, participants, and recipients. We examined perceptions of transplant success and preferences for five upper extremity vascularized composite allotransplantation outcomes. Qualitative data were analyzed using thematic analysis; and quantitative data were analyzed using descriptive statistics. Results: In all, 50 individuals participated in interviews (61.7% participation rate), and 37 participated in nine focus groups (75.5% participation rate). Most were White (72%, 73%), had a mean age of 45 and 48 years, and had a unilateral amputation (84%, 59%), respectively. Participants conceptualized upper extremity vascularized composite allotransplantation success as transplant outcomes: (1) restoring function and sensation to enable new activities; (2) accepting the transplanted limb into one's identity and appearance; (3) not having transplant rejection; (4) attaining greater quality of life compared to prosthetics; and (5) ensuring benefits outweigh risks. Participants rated their most important upper extremity vascularized composite allotransplantation outcomes as follows: not having transplant rejection, not developing health complications, grasping objects, feeling touch and temperature, and accepting the upper extremity vascularized composite allotransplantation into your identity. Conclusion: Individuals with upper extremity amputations maintain several conceptions of vascularized composite allotransplantation success, spanning functional, psychosocial, clinical, and quality of life outcomes. Providers should address patients' conceptions of success to improve informed consent discussions and outcomes reporting for upper extremity vascularized composite allotransplantation.

Patient preferences of patient selection criteria for upper extremity vascularized composite allotransplantation: A qualitative study.

Background: Upper extremity vascularized composite allotransplantation is a life-enhancing reconstructive treatment option that aims to improve recipients' quality of life and maximize function. This study assessed upper extremity vascularized composite allotransplantation patient selection criteria perceptions among individuals with upper extremity limb loss. The perceptions of individuals with upper extremity limb loss on patient selection criteria may enable vascularized composite allotransplantation centers to improve criteria to avoid mismatched expectations about the posttransplant vascularized composite allotransplantation experience and outcomes. Realistic patient expectations may increase patient adherence, improve outcomes, and reduce vascularized composite allotransplantation graft loss. Methods: We conducted in-depth interviews with civilian and military service members with upper extremity limb loss and upper extremity vascularized composite allotransplantation candidates, participants, and recipients from three US institutions. Interviews assessed perceptions of patient selection criteria for suitability as a candidate for upper extremity vascularized composite allotransplantation. Thematic analysis was used to analyze qualitative data. Results: A total of 50 individuals participated (66% participation rate). Most participants were male (78%), White (72%), with a unilateral limb loss (84%), and a mean age of 45 years. Six themes emerged regarding upper extremity vascularized composite allotransplantation patient selection criteria, including support for candidates who: (1) are of younger age, (2) are in good physical health, (3) have mental stability, (4) are willing to "put in the work," (5) have specific amputation characteristics, and (6) have sufficient social support. Patients had preferences about selecting candidates with unilateral versus bilateral limb loss. Conclusions: Our findings suggest that numerous factors, including medical, social, and psychological characteristics, inform patients' perceptions of patient selection criteria for upper extremity vascularized composite allotransplantation. Patient perceptions of patient selection criteria should inform the development of validated screening measures that optimize patient outcomes.

Novel Approach for Umbilical Hernia Repair Using Mesh Strips.

Umbilical hernia repair is a common surgical procedure without a universally accepted means of repair. We introduce a novel surgical technique for open primary umbilical hernia repair, using strips of polypropylene mesh as sutures to achieve a repair. Methods: Two-centimeter-wide strips of macroporous polypropylene mesh were passed through the abdominal wall and tied as simple interrupted sutures to achieve umbilical hernia repair. A retrospective review of all elective umbilical hernia repairs performed by a single surgeon using the mesh strip technique between 2016 and 2021 was conducted, and patient-reported outcomes were assessed via a telephonic survey. Results: Thirty-three patients underwent an elective, open mesh strip repair of a primary umbilical hernia and met criteria for inclusion in the study. Of these patients, 60% responded to a patient-reported outcomes telephone survey. Ninety percent of survey responders reported a pain score of 0 of 10. Additionally, 90% reported being unable to feel or palpate the knot, and 80% reported an improvement in quality of life. Mean follow-up at 3 years revealed one recurrence in the setting of ascites, yielding a recurrence rate of 3%. Conclusion: Primary mesh strip repair of umbilical hernias combines the simplicity of suture repair with the advantageous force distribution properties of mesh, and constitutes a safe, efficient, and effective method of repair with a low recurrence rate at long-term follow-up that is comparable to planar mesh repair.

A Consensus Approach for Targeted Muscle Reinnervation in Amputees.

Amputations have been performed with few modifications since the dawn of surgery. Blood vessels are ligated, bones are shortened, and nerves are cut. In a percentage of people, this can result in severe neuropathic, residual limb, and phantom limb pain. Targeted muscle reinnervation is a surgical procedure initially conceived to optimize function for myoelectric prostheses in amputees. Recently, it has been adopted more widely by surgeons for the prevention and treatment of neuropathic pain. Perhaps as a function of its relatively recent development, many authors perform this operation differently, and there has been no overall agreement regarding the principles, indications, technical specifics, and postoperative management guidelines. This article is written as a consensus statement by surgeons focused on the treatment of neuropathic pain and those with extensive experience performing targeted muscle reinnervation. It is designed to serve as a roadmap and template for extremity surgeons to consider when performing targeted muscle reinnervation.

Targeted muscle reinnervation in above knee amputation: surgical technique.

In the United States, an estimated 185,000 individuals undergo amputation of their upper or lower limb. This results in residual limb pain in up to 85% of cases. Targeted muscle reinnervation (TMR) is a technique that has been shown to prevent symptomatic neuroma formation. In this video, the authors demonstrate their technique utilizing TMR at the time of above-the-knee amputation. Coaptations are made to provide motor targets for branches of the saphenous, tibial, and peroneal sensory nerves. At the featured patient's most recent follow-up visit 3 months postoperatively, she reported no stump pain or phantom limb pain. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID2293.

Myoelectric prosthesis hand grasp control following targeted muscle reinnervation in individuals with transradial amputation.

BACKGROUND: Despite the growing availability of multifunctional prosthetic hands, users' control and overall functional abilities with these hands remain limited. The combination of pattern recognition control and targeted muscle reinnervation (TMR) surgery, an innovative technique where amputated nerves are transferred to reinnervate new muscle targets in the residual limb, has been used to improve prosthesis control of individuals with more proximal upper limb amputations (i.e., shoulder disarticulation and transhumeral amputation). OBJECTIVE: The goal of this study was to determine if prosthesis hand grasp control improves following transradial TMR surgery. METHODS: Eight participants were trained to use a multi-articulating hand prosthesis under myoelectric pattern recognition control. All participated in home usage trials pre- and post-TMR surgery. Upper limb outcome measures were collected following each home trial. RESULTS: Three outcome measures (Southampton Hand Assessment Procedure, Jebsen-Taylor Hand Function Test, and Box and Blocks Test) improved 9-12 months post-TMR surgery compared with pre-surgery measures. The Assessment of Capacity for Myoelectric Control and Activities Measure for Upper Limb Amputees outcome measures had no difference pre- and post-surgery. An offline electromyography analysis showed a decrease in grip classification error post-TMR surgery compared to pre-TMR surgery. Additionally, a majority of subjects noted qualitative improvements in their residual limb and phantom limb sensations post-TMR. CONCLUSIONS: The potential for TMR surgery to result in more repeatable muscle contractions, possibly due to the reduction in pain levels and/or changes to phantom limb sensations, may increase functional use of many of the clinically available dexterous prosthetic hands.

User Performance With a Transradial Multi-Articulating Hand Prosthesis During Pattern Recognition and Direct Control Home Use.

With the increasing availability of more advanced prostheses individuals with a transradial amputation can now be fit with single to multi-degree of freedom hands. Reliable and accurate control of these multi-grip hands still remains challenging. This is the first multi-user study to investigate at-home control and use of a multi-grip hand prosthesis under pattern recognition and direct control. Individuals with a transradial amputation were fitted with and trained to use an OSSUR i-Limb Ultra Revolution with Coapt COMPLETE CONTROL system. They participated in two 8-week home trials using the hand under myoelectric direct and pattern recognition control in a randomized order. While at home, participants demonstrated broader usage of grips in pattern recognition compared to direct control. After the home trial, they showed significant improvements in the Assessment of Capacity for Myoelectric Control (ACMC) outcome measure while using pattern recognition control compared to direct control; other outcome measures showed no differences between control styles. Additionally, this study provided a unique opportunity to evaluate EMG signals during home use. Offline analysis of calibration data showed that users were 81.5% [7.1] accurate across a range of three to five grips. Although EMG signal noise was identified during some calibrations, overall EMG quality was sufficient to provide users with control performance at or better than direct control.

A Novel Method of Fibula Flap In Situ Distraction Osteogenesis Prior to Flap Transfer.

BACKGROUND: The fibula flap is the workhorse for mandibular reconstruction, but fibula bone width is not ideal to match mandibular height. In this study, in situ widening of the fibula with distraction osteogenesis before transfer is evaluated as a solution. The authors present a proof of concept of this technique with a patient series, including one patient who has undergone subsequent orthognathic surgery of the reconstructed mandible. METHODS: A retrospective review of patients undergoing the authors' technique was performed. A longitudinal fibula osteotomy was made in situ and distraction was performed in the leg to widen the fibula. After distraction and consolidation periods, flaps were osteotomized and transferred to the mandible. RESULTS: This technique was applied to three patients (ages 9, 11, and 13 years) with Pruzansky III mandibular hypoplasia at the authors' institution over 15 years. In all cases, bony union was achieved. Mean surgical follow-up was 5 years. No significant morbidity occurred at the donor sites. Partial flap resorption was observed a number of years postoperatively in one patient. Temporomandibular joint ankylosis developed in one patient after closed treatment of an unrelated mandible fracture. A sinus tract developed in one patient, requiring débridement of a partial flap necrosis. One patient had orthognathic surgery, including osteotomy of the fibula. CONCLUSIONS: In situ fibula distraction osteogenesis is a novel technique to prelaminate a fibula flap before transfer to the mandible. This method allows for the reconstruction of challenging mandibular defects without compromising bone height, pedicle length, or the ability to perform orthognathic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Development and Initial Validation of a Novel Professional Aesthetic Scale for the Female Abdomen.

BACKGROUND: A growing body of literature describes abdominal aesthetic goals to tailor surgical and nonsurgical treatment options to meet patient goals. The authors aimed to integrate layperson perceptions into the design of a novel professional aesthetic scale for the abdomen. METHODS: An iterative process of expert consensus was used to choose five domains: abdominal muscle lines, abdominal shape, scar, skin, and umbilicus. A survey was developed to measure global and domain-specific aesthetic preferences on five abdomens. This was distributed through Amazon Mechanical Turk to 340 respondents. Principal component analysis was used to integrate survey data into weights for each of the scale's subquestions. Attending plastic surgeons then rated abdomens using the final scale, and reliability and validity were calculated. RESULTS: The final scale included 11 subquestions-hourglass shape, bulges, hernia, infraumbilical skin, supraumbilical skin, umbilicus shape, umbilicus medialization position, umbilicus height position, semilunar lines, central midline depression, and scar-within the five domains. Central midline depression held the highest weight (16.1 percent) when correlated with global aesthetic rating, followed by semilunar lines (15.8 percent) and infraumbilical skin (11.8 percent). The final scale demonstrated strong validity (Pearson r = 0.99) and was rated as easy to use by seven attending plastic surgeons. CONCLUSIONS: The final scale is the first published professional aesthetic scale for the abdomen that aims to integrate layperson opinion. This analysis and survey data provide insights into the importance of 11 components in overall aesthetic appeal of the abdomen.

Suturable Mesh Demonstrates Improved Outcomes over Standard Suture in a Porcine Laparotomy Closure Model.

BACKGROUND: Laparotomy closures fail due to suture pull-through. I hypothesize that a suturable mesh may limit pull-through via mechanisms of force distribution and fibrous encapsulation of the device filaments. METHODS: Fifteen domestic swine 74 kg in size were randomly allocated to three groups for laparotomy closure with either size 0 suturable mesh, number 1 suturable mesh, or number 1 polypropylene. All three devices were placed in running fashion with 1-cm bites and 1-cm travels. Primary endpoints were hernia formation at 13 weeks and a semiquantitative analysis of the histological tissue response. Secondary endpoints included adhesions, surgical site occurrence (SSO), and documentation of "loose sutures." RESULTS: There were numerically fewer hernias in the number 1 suturable mesh group. Nine of the 10 suturable mesh devices were well encapsulated within the tissues and could not be pulled away, whereas four of the five polypropylene sutures were loose. Adhesions were least for number 1 suturable mesh. Histologically, the suturable mesh implanted devices showed good fibrovascular ingrowth and were judged to be "nonirritants." The soft-tissue response was statistically greater (P = 0.006) for the number 1 suturable mesh than for the number 1 polypropylene. CONCLUSIONS: The mechanism by which meshes support closure sites is clearly demonstrated with this model. Suturable mesh has the potential to change surgical algorithms for abdominal wall closure.

Mesh Repair of Rectus Diastasis for Abdominoplasty is Safer than Suture Plication.

Concerns regarding infection, extrusion, and pain have traditionally precluded the use of mesh to treat severe rectus diastasis during abdominoplasty in the United States. We describe a mesh abdominoplasty technique, and we hypothesize that the complication rate using mesh is greater than the complication rate of suture plication. METHODS: Inclusion criteria for mesh abdominoplasty were patients who (1) had retrorectus planar mesh for repair of rectus diastasis, (2) did not have concurrent ventral hernia, and (3) underwent skin tailoring. Patients who underwent rectus plication with suture, and met criteria 2 and 3 above were included in a sample of consecutive standard abdominoplasty patients. The primary endpoint was surgical site occurrence at any time after surgery, as determined with review of their office and hospital medical records. Secondary endpoints included surgical site infection, revision rates, postoperative course, and aesthetics assessed with their last set of office photographs. RESULTS: Surgical site occurrence rate was 0% of the 40 patients in the mesh group and 19% of the 37 patients in the standard group (P = 0.005); rates of soft-tissue revision were 23% in the mesh group and 27% in the standard group (P = 0.84). As to aesthetics, the mesh abdominoplasty patients had mean statistically lower preoperative scores in comparison with the standard plication group (65.8 ± 11.6 versus 70.3 ± 11.4, P = 0.0013). The mesh group had a statistical improvement to 75.9 ± 12.6 (P < 0.0001), whereas the standard plication group improved to 82.5 ± 11.4 (P < 0.0001). CONCLUSIONS: Retrorectus mesh placement in a cohort of patients with severe rectus diastasis had a complication rate lower than that seen in a cohort of patients with less severe rectus diastasis, therefore negating our original hypothesis. This was done without compromising aesthetic improvement.

Targeted Muscle Reinnervation for the Treatment of Neuroma.

Targeted muscle reinnervation (TMR) is the surgical rerouting of severed nerve endings to nearby expendable motor nerve branches. These nerve transfers provide a pathway for axonal growth, limiting the amputated nerve ends' disorganized attempt at regeneration that leads to neuroma formation. In the amputee population, TMR is successful in the treatment and prevention of chronic phantom limb pain and residual limb pain. In the nonamputee population, applications of TMR are ever expanding in the treatment of chronic neuroma pain owing to trauma, compression, or surgery. This article reviews the indications for TMR, preoperative evaluation, and various surgical techniques.

Surgical Treatment of Abdominal Wall Neuromas.

Neuromas are an under-recognized contributor to chronic abdominal pain. Other than after mesh inguinal hernia repair, surgical management of painful abdominal wall neuromas has not been well established in the literature. METHODS: All patients who underwent surgical treatment for painful abdominal wall neuromas by the senior author at Northwestern Memorial Hospital were reviewed. Patients were treated with neuroma excision and allograft nerve reconstruction and/or with targeted muscle reinnervation (TMR). Follow-up pain surveys were issued to assess pain levels, activities of daily living, and pain medication usage. RESULTS: Twenty patients met inclusion criteria. Eighteen (90%) patients reported improvement in neuropathic pain postoperatively. Two (10%) patients had TMR following failed nerve allograft reconstruction, which led to complete pain resolution. Twenty-seven nerves were treated surgically, the majority of which were abdominal intercostal (13), followed by ilioinguinal (10), genitofemoral (3), and iliohypogastric (1). Nerve allograft reconstruction was used alone for 18 procedures, in combination with TMR for 2, and TMR was used alone in 8. In all cases of TMR, the freshened nerve ending after neuroma excision was coapted to a motor nerve of the internal oblique. The mean length of follow-up was 18.9 months (SD ±14.5). CONCLUSIONS: This retrospective review demonstrated that 90% (18) of the patients had significant improvement in abdominal neuroma pain postoperatively. These results may help guide providers toward effective management of abdominal wall neuropathic pain.

Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene.

Symmetric peripheral gangrene (SPG) affects peripheral tissues of critically ill patients and can have severe disfiguring and debilitating effects. It can occur in the setting of multiple conditions, and it is associated with the use of vasopressors. There are no evidence-based treatments available for patients who develop SPG. Botulinum toxin has emerged as a potential therapy in vasospastic disorders, and we hypothesized that it may be used in the treatment of tissue ischemia in critically ill patients on vasopressors. We present a case of a patient who developed vasopressor-associated SPG and who experienced complete resolution after local injection with botulinum toxin. While the action of botulinum toxin on skeletal muscle is best understood, it has also been demonstrated to attenuate the release of multiple vasoconstrictive factors that impact vascular smooth muscle and modulate calcium and nitric oxide. These effects may result in vasodilation and improvement of cutaneous ischemia when injected locally. Clinicians may consider this local therapy in the treatment of vasopressor-associated symmetric peripheral gangrene.