Vastus Lateralis Transfer for Reconstruction of Hip Abduction following Superior Gluteal Nerve Injury.

A 71-year-old man who had hip abductor insufficiency due to a chronic injury to the right superior gluteal nerve injury after lipoma resection presented to our outpatient clinic 1.5 years postoperatively with persistent pain, atrophy of the gluteus medius muscle, and Trendelenburg sign with a corresponding limp. A magnetic resonance imaging scan and neurophysiological diagnostics confirmed a chronic lesion of the superior gluteal nerve with completed reinnervation and absent pathological spontaneous activity, excluding neurosurgical options to restore hip abduction. Following interdisciplinary evaluation of the patient's case, we performed a vastus lateralis transfer in May 2023 to stabilize the right hip joint. The entire vastus lateralis muscle was carefully freed from the surrounding tissue, and its attachment to the quadriceps tendon was separated. The proximal section of the lateral vastus was then fixed to the ilium and greater trochanter, while the muscle's distal portion was sutured to a more proximal part of the quadriceps muscle. The postoperative course was without any complications, and the patient left the hospital with an abduction splint 10 days after surgery. When he presented to our outpatient clinic 10 weeks after surgery, he reported a significantly improved gait and reduction of pain. Trendelenburg sign was now absent, but right knee function was not impaired and the patient was able to ambulate without the regular need for an orthosis. A transfer of the vastus lateralis muscle is therefore a valuable option to restore hip abductor function in cases of chronic nerve lesions which exclude neurosurgical options.

[Interdisciplinary Treatment Of Tumorous And Tumour-Like Lesions Of Peripheral Nerves]. / Interdisziplinäre Behandlung von Raumforderungen in Assoziation zu peripheren Nerven: Tumore und tumorähnliche Läsionen.

Tumorous or tumour-like lesions of peripheral nerves are generally rare, heterogeneous and challenging to diagnose and treat. They may become apparent by a palpable swelling (lump) near nerves, sensory and/or motor deficits, pain to touch or neuropathic pain. In 91% of cases, tumours are benign. The differentiation of entities and their characteristics as well as a function-preserving resection strategy are highly relevant. Misdiagnosis and inadequate treatment can lead to severe deficits and pain syndromes. Benign tumours include schwannomas and neurofibromas, which can occur sporadically but can also be associated with neurogenetic tumour disposition syndromes if they occur more frequently. Rarer benign nerve tumours include perineuriomas, lipomas, aggressive fibrosis (desmoid tumours), paragangliomas and haemangiomas. Ganglion cysts are described as tumour-like lesions. The association of nerve tumours with neurogenetic syndromes and the correct classification of potentially malignant lesions such as MPNST (malignant peripheral nerve sheath tumour) or intermediate stages such as ANNUBPs (atypical neurofibromatous neoplasms with unknown biological potential) pose particular challenges. Interdisciplinarity is highly relevant for clinical treatment and a correct diagnosis. The aim of our work is to provide an overview of the relevant entities, diagnostic evaluation and contemporary treatment strategies based on the current data situation and taking into account the recently published interdisciplinary AWMF S2k guideline "Diagnosis and Treatment of Peripheral Nerve Tumours".

[Surgical procedures for treatment of spasticity]. / Chirurgische Verfahren zur Therapie von Spastik.

BACKGROUND: The causes of spasticity are various and include cerebral palsy, spinal cord injury, stroke, multiple sclerosis or other congenital or acquired lesions of the central nervous system (CNS). While there is often a partial functional component, spasticity also results in varying degrees of impairment of the quality of life. OBJECTIVE: A review of surgical treatment options for spasticity. MATERIAL AND METHODS: A systematic PubMed review of the literature on epidemiology and treatment options with a focus on neurosurgical interventions for spasticity and developments in the last 20 years as well as inclusion of still valid older landmark papers was carried out. Illustration of indications, technique, follow-up, and possible pitfalls of the different methods for the surgical treatment of spasticity. RESULTS: Depending on the affected region, the number of muscle groups, and the extent of spasticity, focal (selective peripheral neurotomy, nerve transfer), regional (selective dorsal rhizotomy), or generalized (baclofen pump) procedures can be performed. The indications are usually established by an interdisciplinary team. Conservative (physiotherapy, oral medications) and focally invasive (botulinum toxin injections) methods should be performed in advance. In cases of insufficient response to treatment or only short-term relief, surgical methods can be evaluated. These are usually preceded by test phases with, for example, trial injections. CONCLUSION: Surgical methods are a useful adjunct in cases of insufficient response to conservative treatment in children and adults with spasticity.

[Diagnostics and surgical treatment of painful neuromas]. / Diagnostik und chirurgische Therapie schmerzhafter Neurome.

BACKGROUND: Painful neuromas that often develop after peripheral nerve injury require adequate diagnosis and treatment because of the suffering they cause. The scientific basis for the development of painful neuromas has not yet been sufficiently investigated. In addition to conservative procedures, a larger number of surgical techniques are available for treatment of painful neuromas. OBJECTIVE: A review of the basic principles, diagnostic and treatment options for painful neuromas. MATERIAL AND METHODS: Presentation of the scientific basis regarding the development of painful neuromas. Illustration and discussion of the most common diagnostic and treatment procedures. RESULTS: The scientific basis regarding the development of painful neuromas after peripheral nerve injury has not yet been adequately developed. In order to be able to make a correct diagnosis, the use of standardized diagnostic criteria and adequate imaging techniques are recommended. In the sense of a paradigm shift, the use of the formerly neuroma-bearing nerve for reinnervation of target organs is to be preferred over mere burying in adjacent tissue. CONCLUSION: In addition to standardized diagnostics the management of painful neuromas often requires a surgical intervention after all conservative therapeutic measures have been exhausted. As an alternative to restoring the continuity of the injured nerve, targeted reinnervation of electively denervated target organs by the formerly neuroma-bearing nerve is preferable over other techniques.

Rationale and design of the peripheral nerve tumor registry: an observational cohort study.

AIM: Peripheral nerve tumors (PNT) are rare lesions. To date, no systematic multicenter studies on epidemiology, clinical symptoms, treatment strategies and outcomes, genetic and histopathologic features, as well as imaging characteristics of PNT were published. The main goal of our PNT Registry is the systematic multicenter investigation to improve our understanding of PNT and to assist future interventional studies in establishing hypotheses, determining potential endpoints, and assessing treatment efficacy. METHODS: Aims of the PNT registry were set at the 2015 Meeting of the Section of Peripheral Nerve Surgery of the German Society of Neurosurgery. A study protocol was developed by specialists in PNT care. A minimal data set on clinical status, treatment types and outcomes is reported by each participating center at initial contact with the patient and after 1 year, 2 years, and 5 years. Since the study is coordinated by the Charité Berlin, the PNR Registry was approved by the Charité ethics committee (EA4/058/17) and registered with the German Trials Registry (www.drks.de). On a national level, patient inclusion began in June 2016. The registry was rolled out across Europe at the 2019 meeting of the European Association of Neurosurgery in Dublin. RESULTS: Patient recruitment has been initiated at 10 centers throughout Europe and 14 additional centers are currently applying for local ethics approval. CONCLUSION: To date, the PNT registry has grown into an international study group with regular scientific and clinical exchange awaiting the first results of the retrospective study arm.

Outcome After Reconstruction of 43 Digital Nerve Defects With Muscle-in-Vein Conduits.

PURPOSE: Muscle-in-vein conduits provide an alternative for bridging digital nerve defects when tension-free suture is not possible. Low donor site morbidity and absence of additional costs are favorable advantages compared with autografts or conduits. METHODS: We retrospectively reviewed 37 patients with 43 defects of proper palmar digital nerves. Primary repair by muscle-in-vein conduits was performed in 22 cases, whereas 21 cases underwent secondary reconstruction. Recovery of sensibility was assessed using static and moving 2-point discrimination and Semmes-Weinstein monofilament testing. Results were compared with the contralateral side serving as a control. Outcome data were stratified according to international guidelines and evaluated for differences in terms of age, gap length, time of reconstruction, and concomitant injuries. RESULTS: The median gap length was 20 mm (range, 9-60 mm). After a median follow-up of 25.0 months (interquartile range, 29.0 months), the median static and moving 2-point discrimination were 7.0 mm and 5.0 mm (interquartile range, 3.0 mm), respectively. The evaluation with Semmes-Weinstein monofilament revealed a median reduction of sensibility of 2 levels compared with the contralateral side. According to the American Society for Surgery of the Hand guidelines, 81.4% of the results were classified as excellent or good, whereas fair and poor results were noted in 9.3% of the cases each. The modified Highet and Sander's criteria rated complete clinical recovery in 13 cases; 23 results were regarded as S3+. CONCLUSIONS: Muscle-in-vein conduits can be considered for primary and secondary reconstruction of digital nerves. Successful sensory recovery in terms of measurable 2-point discrimination was achieved in 91% of all cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Postoperative complications and oncologic outcomes after multimodal therapy of localized high risk soft tissue sarcoma.

BACKGROUND: Standard therapy for localized high-risk soft tissue sarcoma includes surgical resection and neoadjuvant or adjuvant radiation therapy (± chemotherapy and locoregional hyperthermia). No difference in oncologic outcomes for patients treated with neoadjuvant and adjuvant radiation therapy was reported, whereas side effect profiles differ. The aim of this analysis was to analyse oncologic outcomes and postoperative complications in patients treated with multimodal treatment. METHODS: Oncologic outcomes and major wound complications (MWC, subclassified as wound healing disorder, infection, abscess, fistula, seroma and hematoma) were evaluated in 74 patients with localized high-risk soft tissue sarcoma of extremities and trunk undergoing multimodal treatment, and also separately for the subgroup of lower extremity tumors. Clinical factors and treatment modalities (especially neoadjuvant vs. adjuvant radiotherapy) were evaluated regarding their prognostic value and impact on postoperative wound complications. RESULTS: Oncologic outcomes were dependent on number of high risk features (tumor size, depth to superficial fascia and grading), but not on therapy sequencing (however with higher risk patients in the neoadjuvant group). Different risk factors influenced different subclasses of wound healing complications. Slightly higher MWC-rates were observed in patients treated with neoadjuvant therapy, compared to adjuvant radiotherapy, although only with a trend to statistical significance (31.8% vs. 13.3%, p = 0.059). However, except for wound infections, no significant difference for other subclasses of postoperative complications was observed between neoadjuvant and adjuvant therapy. Diabetes was confirmed as a major risk factor for immune-related wound complications. CONCLUSION: Rates of major wound complications in this cohort are comparable to published data, higher rates of wound infections were observed after neoadjuvant radiotherapy. Tumor localization, patient age and diabetes seem to be major risk factors. The number of risk factors for high risk soft tissue sarcoma seem to influence DMFS. Neoadjuvant treatment increases the risk only for wound infection treated with oral or intravenous antibiotic therapy and appears to be a safe option at an experienced tertiary center in absence of other risk factors.

Naming the Barriers between Anti-CCR5 Therapy, Breast Cancer and Its Microenvironment.

Breast cancer represents the most common malignancy among women in the world. Although immuno-, chemo- and radiation therapy are widely recognized as the therapeutic trifecta, new strategies in the fight against breast cancer are continually explored. The local microenvironment around the tumor plays a great role in cancer progression and invasion, representing a promising therapeutic target. CCL5 is a potent chemokine with a physiological role of immune cell attraction and has gained particular attention in R&D for breast cancer treatment. Its receptor, CCR5, is a well-known co-factor for HIV entry through the cell membrane. Interestingly, biology research is unusually unified in describing CCL5 as a pro-oncogenic factor, especially in breast cancer. In silico, in vitro and in vivo studies blocking the CCL5/CCR5 axis show cancer cells become less invasive and less malignant, and the extracellular matrices produced are less oncogenic. At present, CCR5 blocking is a mainstay of HIV treatment, but despite its promising role in cancer treatment, CCR5 blocking in breast cancer remains unperformed. This review presents the role of the CCL5/CCR5 axis and its effector mechanisms, and names the most prominent hurdles for the clinical adoption of anti-CCR5 drugs in cancer.

Does leg dominance influence anterolateral thigh flap perforators?

INTRODUCTION: Thorough knowledge of perforator anatomy can facilitate anterolateral thigh (ALT) free flap harvest. The selection of the right or left thigh as donor area may be supported by preoperative perforator imaging and practical considerations. The study aims to determine if the leg dominance should be taken into account, when choosing the donor thigh for ALT free flap harvest, as muscle mass and perfusion might influence perforator quantity. METHODS: ALT perforators were localized by color-coded duplex sonography and dynamic infrared thermography on both thighs within a defined 250 × 80 mm area in 24 subjects. Perforator number and thickness of subcutaneous tissue and muscle layer were compared in dominant and nondominant legs. RESULTS: We found no statistically significant difference comparing sonographically identified ALT perforator numbers and hot spot numbers in dominant and nondominant legs. Yet, we found high interindividual differences. The comparison of subcutaneous tissue and muscle thickness yielded no significant difference. CONCLUSIONS: Our study yielded no evidence for preference of the dominant or nondominant leg in ALT free flap harvesting. As we found high interindividual differences in perforator number, we suggest to rely on preoperative perforator imaging when choosing the ALT free flap donor thigh.

Postoperative Remote Ischemic Conditioning (RIC) significantly improves entire flap microcirculation beyond 4 hours.

OBJECTIVE: Free flap transfer is a safe and reliable technique for soft tissue reconstruction. However, impaired flap perfusion with consecutive microcirculatory failure leading to partial or total flap failure remains a clinically relevant problem. Remote ischemic conditioning (RIC) has been shown to improve microcirculation in adipo-cutaneous tissues in healthy humans as well as in free flaps. Yet, little is known about its effects on different perfusion zones in free flaps and the duration of these effects. METHODS: Twenty-five patients with free perforator-based adipo-cutaneous flap transfer were included in the study. RIC (3 cycles: 10/10 min ischemia/reperfusion) was applied via an inflatable tourniquet placed on the upper arm. Continuous measurement of flaps' microcirculation on postoperative day (POD) 1, 3, and 5 was performed by utilizing an O2C device ("Oxygen-to-see" ©LEA Medizintechnik Germany) during RIC and for the following 4 h. Probes were located both in the flaps' center and on its distal edge. RESULTS: Twenty patients were included in the final analysis. RIC significantly improved flaps' blood flow (BF) by a max. of + 19.6% and oxygen saturation of + 15.7%. Changes affected the entire flap, without significant difference between zones. The increase in flap perfusion could be observed for at least 4 h after the completion of RIC. CONCLUSION: Postoperative application of RIC might serve as an additional treatment to enhance whole flap perfusion and prevent microcirculatory disorders, therefore reducing the risk for potential tissue necrosis, especially in the distal parts of the flaps.

Muscle-in-Vein Conduits for the Treatment of Symptomatic Neuroma of Sensory Digital Nerves.

BACKGROUND: Considering the debilitating burden of neuroma resulting in a significant loss of function and excruciating pain, the use of muscle-in-vein conduits (MVCs) for the reconstruction of painful neuroma of sensory nerves of the fingers was assessed. METHODS: We retrospectively analyzed 10 patients who underwent secondary digital nerve repair by MVCs. The recovery of sensibility was evaluated by static and moving two-point discrimination (2PDs, 2PDm) and Semmes-Weinstein monofilament testing (SWM). The minimum follow-up was set 12 months after the operation. RESULTS: The median period between trauma and nerve repair was 13.4 weeks (IQR 53.5). After neuroma resection, defects ranged from 10-35 mm (mean 17.7 mm, SD 0.75). The successful recovery of sensibility was achieved in 90% of patients after a median follow-up of 27.0 months (IQR 31.00). The mean 2PDs and 2PDm was 8.1 mm (SD 3.52) and 5.2 mm (SD 2.27), respectively. Assessment by SWM resulted in a mean value of 3.54 (SD 0.69). Reduction in pain was achieved among all patients; eight patients reported the complete relief of neuropathic pain. There was no recurrence of neuroma in any patient. CONCLUSIONS: Muscle-in-vein conduits provide an effective treatment for painful neuroma of digital nerves, resulting in satisfactory restoration of sensory function and relief of pain.

Microcurrent Reverses Cigarette Smoke-Induced Angiogenesis Impairment in Human Keratinocytes In Vitro.

Cigarette smoking (CS) leads to several adverse health effects, including diseases, disabilities, and even death. Post-operative and trauma patients who smoke have an increased risk for complications, such as delayed bone or wound healing. In clinical trials, microcurrent (MC) has been shown to be a safe, non-invasive, and effective way to accelerate wound healing. Our study aimed to investigate if MC with the strength of 100 µA may be beneficial in treating CS-related healing impairment, especially in regard to angiogenesis. In this study, we investigated the effect of human keratinocyte cells (HaCaT) on angiogenesis after 72 h of cigarette smoke extract (CSE) exposure in the presence or absence of 100 µA MC. Cell viability and proliferation were evaluated by resazurin conversion, Sulforhodamine B, and Calcein-AM/Hoechst 33342 staining; the pro-angiogenic potential of HaCaT cells was evaluated by tube formation assay and angiogenesis array assay; signaling pathway alterations were investigated using Western blot. Constant exposure for 72 h to a 100 µA MC enhanced the angiogenic ability of HaCaT cells, which was mediated through the PI3K-Akt signaling pathway. In conclusion, the current data indicate that 100 µA MC may support wound healing in smoking patients by enhancing angiogenesis.

The Role of CDK Pathway Dysregulation and Its Therapeutic Potential in Soft Tissue Sarcoma.

Soft tissue sarcomas (STSs) are tumors that are challenging to treat due to their pathologic and molecular heterogeneity and their tumor biology that is not yet fully understood. Recent research indicates that dysregulation of cyclin-dependent kinase (CDK) signaling pathways can be a strong driver of sarcogenesis. CDKs are enzyme forms that play a crucial role in cell-cycle control and transcription. They belong to the protein kinases group and to the serine/threonine kinases subgroup. Recently identified CDK/cyclin complexes and established CDK/cyclin complexes that regulate the cell cycle are involved in the regulation of gene expression through phosphorylation of critical components of transcription and pre-mRNA processing mechanisms. The current and continually growing body of data shows that CDKs play a decisive role in tumor development and are involved in the proliferation and growth of sarcoma cells. Since the abnormal expression or activation of large numbers of CDKs is considered to be characteristic of cancer development and progression, dysregulation of the CDK signaling pathways occurs in many subtypes of STSs. This review discusses how reversal and regulation can be achieved with new therapeutics and summarizes the current evidence from studies regarding CDK modulation for STS treatment.

Irradiated Triple-Negative Breast Cancer Co-Culture Produces a Less Oncogenic Extracellular Matrix.

Triple-negative breast cancer is the most common and most deadly cancer among women. Radiation is a mainstay of treatment, administered after surgery, and used in the hope that any remaining cancer cells will be destroyed. While the cancer cell response is normally the focus of radiation therapy, little is known about the tumor microenvironment response after irradiation. It is widely reported that increased collagen expression and deposition are associated with cancer progression and poor prognosis in breast cancer patients. Aside from the classical fibrotic response, ratios of collagen isoforms have not been studied in a radiated tumor microenvironment. Here, we created one healthy co-culture of stromal fibroblasts and adipose-derived stem cells, and one triple-negative breast cancer co-culture, made of stromal fibroblasts, adipose derived stem cells, and triple-negative breast cancer cells. After irradiation, growth and decellularization of co-cultures, we reseeded the breast cancer cells for 24 h and analyzed the samples using mass spectrometry. Proteomic analysis revealed that collagen VI, a highly oncogenic collagen isoform linked to breast cancer, was decreased in the irradiated cancer co-culture. This indicates that the anti-cancer impact of radiation may be not only cell ablative, but also influential in creating a less oncogenic microenvironment.

Multihit Injury of the Radial Nerve in a 62-year-old Woman: A Case Report.

We report the case of a 62-year-old female patient with a triple-crush radial nerve injury, diagnosed in subsequent order following a fracture of the left humerus. The patient developed flaccid paralysis of all muscles innervated by the left radial nerve except the triceps brachii and reported a sensory deficit corresponding to the innervation territories of the posterior nerve of the forearm as well as the superficial branch of the radial nerve. Following neurolysis of the radial nerve at the humerus level, wrist extension as well as sensory perception on the dorsal aspect of the forearm recovered, but finger extension and thumb abduction were still impossible. Following neurological evaluation and nerve ultrasound, supinator syndrome was diagnosed and the patient underwent decompression surgery. Following surgical decompression, motor recovery was observable but a sensory deficit remained in the area innervated by the superficial branch of the radial nerve. In consequence, the third crush injury of the left radial nerve, that is, Wartenberg syndrome or cheiralgia paraesthetica was diagnosed. Decompression surgery of the superficial branch of the radial nerve was performed and the patient reported profound amelioration of her sensory symptoms during a follow-up examination at our outpatient clinic 6 weeks postoperatively.

Septic arthritis of the wrist: a retrospective review of 39 cases.

LEVEL OF EVIDENCE: III.

Air Flow Cooling Improves Anterolateral Thigh Perforator Mapping Using the FLIR ONE Thermal Camera.

BACKGROUND: Due to the variable vascular anatomy preoperative perforator mapping facilitates anterolateral thigh (ALT) free flap harvesting. Dynamic infrared perforator imaging can assist preoperative planning by displaying hot spots that represent angiosomes. This study aims to compare previously described precooling methods to develop a standardized simplified protocol for ALT perforator planning. METHODS: Fifty thighs were examined with a FLIR ONE thermal camera. Four different cold challenges, including alcoholic disinfection, wet laparotomy sponge cooling, fan cooling, and cold pack application, were compared. Hot spot locations within a 250 mm × 80 mm area were compared double-blinded to perforator locations determined by Doppler ultrasonography considered as gold standard. RESULTS: The matching rate of thermographic hot spots and sonographically identified perforators was 34.9 ± 22.2%. An increased matching rate of 62.2 ± 42.2% was noted taking only favored perforators (septocutaneous course, diameter >1 mm, distance <3 cm to the center, and visible concomitant veins) into account. Precooling with a fan followed by alcoholic disinfection provided clearest thermograms and fastest results. CONCLUSION: Thermographic imaging is a reliable method for perforator imaging. Its supplemental use to ultrasound may reduce examination time and yield additional information. Precooling by air flow or alcoholic disinfection can be easily implemented and provide the best thermograms. The matching rate of thermographic hot spots and perforators increases when taking only clinically relevant perforators into account. Thermal perforator mapping therefore reduces distraction by negligible perforators.

Hypofractionated preoperative radiotherapy for high risk soft tissue sarcomas in a geriatric patient population.

BACKGROUND: Standard therapy for localised, resectable high risk soft tissue sarcomas consists of wide excision and radiotherapy over several weeks. This treatment schedule is hardly feasible in geriatric and frail patients. In order not to withhold radiotherapy from these patients, hypofractionated radiotherapy with 25 Gy in 5 fractions was evaluated in a geriatric patient population. PATIENTS AND METHODS: A retrospective analysis was performed of 18 geriatric patients with resectable high risk soft tissue sarcomas of extremities and thoracic wall. Wound healing and short term oncologic outcome were analysed. In addition, dose constraints for radiotherapy of the extremities were transferred from normofractionated to hypofractionated radiotherapy regimens. RESULTS: Feasibility was good with 17/18 patients completing treatment as planned. Wound healing complication rate was in the range of published data. Two patients developed local and distant recurrence, two patients isolated distant recurrences. No isolated local recurrences were observed. Keeping the constraints was possible in all cases without compromising the coverage of the target volume. CONCLUSIONS: Hypofractionated radiotherapy and surgery was well tolerated even in this specific patient population. With feasibility concerning early wound healing problems and adapted constraints, which allow for the treatment of most resectable extremity tumours, the concept warrants further evaluation in patients unfit for standard radiotherapy.

Beyond the Knife-Reviewing the Interplay of Psychosocial Factors and Peripheral Nerve Lesions.

Peripheral nerve injuries are a common clinical problem. They not only affect the physical capabilities of the injured person due to loss of motor or sensory function but also have a significant impact on psychosocial aspects of life. The aim of this work is to review the interplay of psychosocial factors and peripheral nerve lesions. By reviewing the published literature, we identified several factors to be heavily influenced by peripheral nerve lesions. In addition to psychological factors like pain, depression, catastrophizing and stress, social factors like employment status and worker's compensation status could be identified to be influenced by peripheral nerve lesions as well as serving as predictors of functional outcome themselves, respectively. This work sheds a light not only on the impact of peripheral nerve lesions on psychosocial aspects of life, but also on the prognostic values of these factors of functional outcome. Interdisciplinary, individualized treatment of patients is required to identify patient at risk for adverse outcomes and provide them with emotional support when adapting to their new life situation.

Reduction of Phantom Limb Pain and Improved Proprioception through a TSR-Based Surgical Technique: A Case Series of Four Patients with Lower Limb Amputation.

Four patients underwent targeted sensory reinnervation (TSR), a surgical technique in which a defined skin area is first selectively denervated and then surgically reinnervated by another sensory nerve. In our case, either the area of the lateral femoral cutaneous nerve or the saphenous nerve was reinnervated by the sural nerve. Patients were then fitted with a special prosthetic device capable of transferring the sense of pressure from the sole of the prosthesis to the newly wired skin area. Pain reduction after TSR was highly significant in all patients. In three patients, permanent pain medication could even be discontinued, in one patient the pain medication has been significantly reduced. Two of the four patients were completely pain-free after the surgical intervention. Surgical rewiring of existing sensory nerves by TSR can provide the brain with new afferent signals seeming to originate from the missing limb. These signals help to reduce phantom limb pain and to restore a more normal body image. In combination with special prosthetic devices, the amputee can be provided with sensory feedback from the prosthesis, thus improving gait and balance.