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OBJECTIVE: This study analyses the anatomy and sensory outcomes of targeted nipple areola complex reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafting (FNG). BACKGROUND: TNR is a novel technique to preserve and reconstruct intercostal nerves (ICN) to improve postoperative sensation. There is little evidence on relevant anatomy and outcomes. METHODS: 25 patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient reported questionnaires were completed preoperatively, and at one, three, six, nine and twelve months postoperatively. RESULTS: 50 mastectomies were performed. Per mastectomy, the median number of ICN found and used was 2 (1-5). Axon and fascicle counts were not significantly different between ICN branches ( P >0.05). BMI ≥30 kg/m 2 and mastectomy weight ≥800 g were associated with significantly worse preoperative sensation ( P <0.05). Compared to preoperative values, NAC sensation was worse at 1 month ( P <0.01), comparable at 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. Chest sensation was comparable to the preoperative measurements at 1 and 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. NAC sensation was significantly better when direct coaptation was performed compared to use of allograft only ( P <0.05), and with direct coaptation of ≥2 branches compared to direct coaptation of a single branch ( P <0.05). All patients reported return of nipple and chest sensation at one year postoperatively and 88% reported return of some degree of erogenous sensation. CONCLUSION: TNR allows for restoration of NAC and chest sensation within 3 months postoperatively. Use of multiple ICN branches and direct coaptation led to the best sensory outcomes.
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INTRODUCTION: The biology of symptomatic neuromas is poorly understood, particularly the factors causing pain in human neuromas. Pain presence varies among and within individuals, with some having painful and nonpainful neuromas. To bridge these knowledge gaps, our group developed a protocol for assessing neuroma pain and collecting tissue for molecular analysis. This manuscript outlines our workflow and challenges and aims to inspire other centers to share their experiences with these tissues. METHODS: For every included patient and collected nerve or bone tissue specimens, we perform a detailed chart review and a multifaceted analysis of pain and pain perception immediately before surgery. We collect patient-reported outcome measures (PROMs) on pain, function, and mental well-being outcomes at preoperative assessment and at the 6-month follow-up postoperatively. Before surgery, the patient is assessed once again to obtain an immediate preoperative pain status and identify potential differences in pain intensity of different neuromas. Intraoperatively, specimens are obtained and their gross anatomical features are recorded, after which they are stored in paraformaldehyde or frozen for later sample analyses. Postoperatively, patients are contacted to obtain additional postoperative PROMs. RESULTS: A total of 220 specimens of nerve tissue have been successfully obtained from 83 limbs, comprising 95 specimens of neuromas and 125 specimens of nerves located proximal to the neuromas or from controls. CONCLUSIONS: Our approach outlines the methods combining specimen collection and examination, including both macroscopic and molecular biological features, with PROMs, encompassing physical and psychological aspects, along with clinical metadata obtained through clinical teams and chart review.
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Neuroma , Dimensión del Dolor , Medición de Resultados Informados por el Paciente , Manejo de Especímenes , Humanos , Neuroma/diagnóstico , Manejo de Especímenes/normas , Manejo de Especímenes/métodos , Femenino , Persona de Mediana Edad , Masculino , Adulto , Documentación/normas , AncianoRESUMEN
INTRODUCTION: Targeted muscle reinnervation (TMR) is an effective surgical treatment of neuropathic pain for amputees. However, limited data exists regarding the early post-operative pain course for patients who undergo either Primary (<14 days since amputation) or Secondary (≥14 days) TMR. This study aims to outline the post-operative pain course for Primary and Secondary TMR during the first six post-operative months, to aid in patient education and expectation management. METHODS: Patients were eligible if they underwent TMR surgery between 2017 and 2023. Prospectively collected patient-reported outcome measures of pain scores, Pain Interference, and Pain Intensity were analyzed. Multilevel mixed-effect models were utilized to visualize and compare pain courses between Primary and Secondary TMR patients. RESULTS: A total of 203 amputees were included, with 40.9% being Primary and 59.1% being Secondary TMR patients. Primary TMR patients reported significantly lower pain scores over the full 6-month post-operative trajectory (p<0.001) compared to Secondary TMR patients, with a difference of Δ-1.0 at day of TMR (Primary=4.5, Secondary=5.5), and a difference of Δ-1.4 at the 6-month mark (Primary=3.6, Secondary=5.0). Primary TMR patients also reported significantly lower Pain Interference (p<0.001) and Pain Intensity scores (p<0.001) over the complete trajectory of their care. CONCLUSION: Primary TMR patients report lower pain during the first six months post-operatively compared to secondary TMR patients. This may reflect how pre-existing neuropathic pain is more challenging to mitigate through peripheral nerve surgery. The current trends may assist in both understanding the post-operative pain course and in managing patient expectations following TMR.
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BACKGROUND: Lower extremity free flap failure rates are higher than in other areas of the body. While prior studies assessed the effect of intraoperative technical variables, these generally investigated individual variables and did not examine relationships between the many individual technical decisions made during free tissue reconstruction. Our purpose was to investigate the effect of variation in intraoperative microsurgical techniques on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage. METHODS: Consecutive patients undergoing free flap reconstruction of the lower extremity at two level 1 trauma centers from January 2002 to January 2020 were identified using Current Procedural Terminology codes, followed by a review of medical records. Information regarding demographics and comorbidities, indications, intraoperative technical details, and complications was collected. Outcomes of interest included an unplanned return to the operating room, arterial thrombosis, venous thrombosis, partial flap failure, and total flap failure. Bivariate analysis was performed. RESULTS: In total, 410 patients underwent 420 free tissue transfers. The median follow-up time was 17 months (interquartile ranges: 8.0-37). Total flap failure occurred in 4.9% (n = 20), partial flap failure in 5.9% (n = 24), and unplanned reoperation in 9.0% (n = 37), with arterial thrombosis in 3.2% (n = 13) and venous thrombosis in 5.4% (n = 22). Overall complications were significantly associated with recipient artery choice, with arteries other than PT and AT/DP having a higher rate (p = 0.033), and with arterial revisions (p = 0.010). Total flap failure was also associated with revision of the arterial anastomosis (p = 0.035), and partial flap failure was associated with recipient artery choice (p = 0.032). CONCLUSION: Many interoperative options and techniques are available when performing microvascular lower extremity reconstruction that leads to equally high success rates. However, the use of arterial inflow outside of the posterior tibial and anterior tibial arteries leads to a higher overall complication rate and partial flap failure rate. Intraoperative revision of the arterial anastomosis portends poorly for ultimate flap survival.
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Colgajos Tisulares Libres , Trombosis de la Vena , Humanos , Colgajos Tisulares Libres/irrigación sanguínea , Resultado del Tratamiento , Estudios Retrospectivos , Extremidad Inferior/cirugía , Extremidad Inferior/lesiones , Complicaciones PosoperatoriasRESUMEN
BACKGROUND: Identifying patients at risk for prolonged opioid use following surgery for symptomatic neuroma would be beneficial for perioperative management. The aim of this study is to identify the factors associated with postoperative opioid use of >4 weeks in patients undergoing neuroma surgery. METHODS: After retrospective identification, 77 patients who underwent surgery for symptomatic neuroma of the upper or lower extremity were enrolled. Patients completed the Patient-Reported Outcomes Measurement Information System (PROMIS) depression, Numeric Rating Scale (NRS) pain score, and a custom medication questionnaire at a median of 9.7 years (range: 2.5-16.8 years) following surgery. Neuroma excision followed by nerve implantation (n = 39, 51%), nerve reconstruction/repair (n = 18, 23%), and excision alone (n = 16, 21%) were the most common surgical treatments. RESULTS: Overall, 27% (n = 21) of patients reported opioid use of more than 4 weeks postoperatively. Twenty-three patients (30%) reported preoperative opioid use of which 11 (48%) did not report opioid use for >4 weeks, postoperatively. In multivariable logistic regression, preoperative opioid use was independently associated with opioid use of >4 weeks, postoperatively (odds ratio [OR] = 4.4, 95% confidence interval [CI]: 1.36-14.3, p = 0.013). CONCLUSION: Neuroma surgery reduces opioid use in many patients but patients who are taking opioids preoperatively are at risk for longer opioid use. Almost one-third of patients reported opioid use longer than 4 weeks, postoperatively.
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Analgésicos Opioides , Neuroma , Humanos , Neuroma/cirugía , Procedimientos Neuroquirúrgicos , Dolor Postoperatorio/tratamiento farmacológico , Estudios RetrospectivosRESUMEN
ABSTRACT: Events causing acute stress to the health care system, such as the COVID-19 pandemic, place clinical decisions under increased scrutiny. The priority and timing of surgical procedures are critically evaluated under these conditions, yet the optimal timing of procedures is a key consideration in any clinical setting. There is currently no single article consolidating a large body of current evidence on timing of nerve surgery. MEDLINE and EMBASE databases were systematically reviewed for clinical data on nerve repair and reconstruction to define the current understanding of timing and other factors affecting outcomes. Special attention was given to sensory, mixed/motor, nerve compression syndromes, and nerve pain. The data presented in this review may assist surgeons in making sound, evidence-based clinical decisions regarding timing of nerve surgery.
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COVID-19 , Procedimientos de Cirugía Plástica , Humanos , Procedimientos Neuroquirúrgicos , Pandemias , SARS-CoV-2RESUMEN
PURPOSE: Targeted muscle reinnervation (TMR) is a technique for the management of peripheral nerves in amputation. Phantom limb pain (PLP) and residual limb pain (RLP) trouble many patients after amputation, and TMR has been shown to reduce this pain when performed after the initial amputation. We hypothesize that TMR at the time of amputation may improve pain for patients after major upper-extremity amputation. METHODS: We conducted a retrospective review of patients who underwent major upper-extremity amputation with TMR performed at the time of the index amputation (early TMR). Phantom limb pain and RLP intensity and associated symptoms were assessed using the numeric rating scale (NRS), the Patient-Reported Outcome Measurement Information System (PROMIS) Pain Intensity Short-Form 3a, the Pain Behavior Short-Form 7a, and the Pain Interference Short-Form 8a. The TMR cohort was compared with benchmarked data from a sample of upper-extremity amputees. RESULTS: Sixteen patients underwent early TMR and were compared with 55 benchmark patients. More than half of early TMR patients were without PLP (62%) compared with 24% of controls. Furthermore, half of all patients were free of RLP compared with 36% of controls. The median PROMIS PLP intensity score for the general sample was 47 versus 38 in the early TMR sample. Patients who underwent early TMR reported reduced pain behaviors and interference specific to PLP (50 vs 53 and 41 vs 50, respectively). The PROMIS RLP intensity score was lower in patients with early TMR (36 vs 47). CONCLUSIONS: This study demonstrates that early TMR is a promising strategy for treating pain and improving the quality of life in the upper-extremity amputee. Early TMR may preclude the need for additional surgery and represents an important technique for peripheral nerve surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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Miembro Fantasma , Calidad de Vida , Amputación Quirúrgica , Humanos , Músculo Esquelético , Estudios RetrospectivosRESUMEN
BACKGROUND: Active treatment (targeted muscle reinnervation [TMR] or regenerative peripheral nerve interfaces [RPNIs]) of the amputated nerve ends has gained momentum to mitigate neuropathic pain following amputation. Therefore, the aim of this study is to determine the predictors for the development of neuropathic pain after major upper extremity amputation. METHODS: Retrospectively, 142 adult patients who underwent 148 amputations of the upper extremity between 2000 and 2019 were identified through medical chart review. All upper extremity amputations proximal to the metacarpophalangeal joints were included. Patients with a follow-up of less than 6 months and those who underwent TMR or RPNI at the time of amputation were excluded. Neuropathic pain was defined as phantom limb pain or a symptomatic neuroma reported in the medical charts at 6 months postoperatively. Most common indications for amputation were oncology (n = 53, 37%) and trauma (n = 45, 32%), with transhumeral amputations (n = 44, 30%) and shoulder amputations (n = 37, 25%) being the most prevalent. RESULTS: Neuropathic pain occurred in 42% of patients, of which 48 (32%) had phantom limb pain, 8 (5.4%) had a symptomatic neuroma, and 6 (4.1%) had a combination of both. In multivariable analysis, traumatic amputations (odds ratio [OR]: 4.1, p = 0.015), transhumeral amputations (OR: 3.9, p = 0.024), and forequarter amputations (OR: 8.4, p = 0.003) were independently associated with the development of neuropathic pain. CONCLUSION: In patients with an upper extremity amputation proximal to the elbow or for trauma, there is an increased risk of developing neuropathic pain. In these patients, primary TMR/RPNI should be considered and this warrants a multidisciplinary approach involving general trauma surgeons, orthopaedic surgeons, plastic surgeons, and vascular surgeons.
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Músculo Esquelético , Neuralgia , Adulto , Amputación Quirúrgica , Muñones de Amputación , Humanos , Neuralgia/etiología , Estudios Retrospectivos , Factores de Riesgo , Extremidad Superior/cirugíaRESUMEN
BACKGROUND: Targeted muscle reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates. METHODS: Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations. RESULTS: A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft. CONCLUSIONS: This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.
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Amputados/rehabilitación , Desarticulación/métodos , Hemipelvectomía/métodos , Músculos/inervación , Músculos/cirugía , Miembro Fantasma/prevención & control , Procedimientos de Cirugía Plástica/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Pronóstico , Estudios RetrospectivosRESUMEN
BACKGROUND: Targeted muscle reinnervation is an emerging surgical technique to treat neuroma pain whereby sensory and mixed motor nerves are transferred to nearby redundant motor nerve branches. In a recent randomized controlled trial, targeted muscle reinnervation was recently shown to reduce postamputation pain relative to conventional neuroma excision and muscle burying. QUESTIONS/PURPOSES: (1) Does targeted muscle reinnervation improve residual limb pain and phantom limb pain in the period before surgery to 1 year after surgery? (2) Does targeted muscle reinnervation improve Patient-reported Outcome Measurement System (PROMIS) pain intensity and pain interference scores at 1 year after surgery? (3) After 1 year, does targeted muscle reinnervation improve functional outcome scores (Orthotics Prosthetics User Survey [OPUS] with Rasch conversion and Neuro-Quality of Life [Neuro-QOL])? METHODS: Data on patients who were ineligible for randomization or declined to be randomized and underwent targeted muscle reinnervation for pain were gathered for the present analysis. Data were collected prospectively from 2013 to 2017. Forty-three patients were enrolled in the study, 10 of whom lacked 1-year follow-up, leaving 33 patients for analysis. The primary outcomes measured were the difference in residual limb and phantom limb pain before and 1 year after surgery, assessed by an 11-point numerical rating scale (NRS). Secondary outcomes were change in PROMIS pain measures and change in limb function, assessed by the OPUS Rasch for upper limbs and Neuro-QOL for lower limbs before and 1 year after surgery. RESULTS: By 1 year after targeted muscle reinnervation, NRS scores for residual limb pain from 6.4 ± 2.6 to 3.6 ± 2.2 (mean difference -2.7 [95% CI -4.2 to -1.3]; p < 0.001) and phantom limb pain decreased from 6.0 ± 3.1 to 3.6 ± 2.9 (mean difference -2.4 [95% CI -3.8 to -0.9]; p < 0.001). PROMIS pain intensity and pain interference scores improved with respect to residual limb and phantom limb pain (residual limb pain intensity: 53.4 ± 9.7 to 44.4 ± 7.9, mean difference -9.0 [95% CI -14.0 to -4.0]; residual limb pain interference: 60.4 ± 9.3 to 51.7 ± 8.2, mean difference -8.7 [95% CI -13.1 to -4.4]; phantom limb pain intensity: 49.3 ± 10.4 to 43.2 ± 9.3, mean difference -6.1 [95% CI -11.3 to -0.9]; phantom limb pain interference: 57.7 ± 10.4 to 50.8 ± 9.8, mean difference -6.9 [95% CI -12.1 to -1.7]; p ≤ 0.012 for all comparisons). On functional assessment, OPUS Rasch scores improved from 53.7 ± 3.4 to 56.4 ± 3.7 (mean difference +2.7 [95% CI 2.3 to 3.2]; p < 0.001) and Neuro-QOL scores improved from 32.9 ± 1.5 to 35.2 ± 1.6 (mean difference +2.3 [95% CI 1.8 to 2.9]; p < 0.001). CONCLUSIONS: Targeted muscle reinnervation demonstrates improvement in residual limb and phantom limb pain parameters in major limb amputees. It should be considered as a first-line surgical treatment option for chronic amputation-related pain in patients with major limb amputations. Additional investigation into the effect on function and quality of life should be performed. LEVEL OF EVIDENCE: Level IV, therapeutic study.
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Dolor Crónico/cirugía , Músculo Esquelético/inervación , Transferencia de Nervios/métodos , Neuroma/cirugía , Miembro Fantasma/cirugía , Adulto , Amputación Quirúrgica/efectos adversos , Dolor Crónico/etiología , Dolor Crónico/fisiopatología , Femenino , Humanos , Extremidad Inferior/inervación , Extremidad Inferior/fisiopatología , Extremidad Inferior/cirugía , Masculino , Persona de Mediana Edad , Músculo Esquelético/cirugía , Neuroma/etiología , Neuroma/fisiopatología , Medición de Resultados Informados por el Paciente , Miembro Fantasma/etiología , Miembro Fantasma/fisiopatología , Estudios Prospectivos , Resultado del Tratamiento , Extremidad Superior/inervación , Extremidad Superior/fisiopatología , Extremidad Superior/cirugíaRESUMEN
Wound infection involving hardware can be notoriously difficult to treat, often requiring the removal of the infected implant. The goal of this study was to determine the utility of instillation negative pressure wound therapy to help eradicate infection and allow for definitive wound closure in patients without removing the infected hardware. A retrospective review was performed on the outcomes of 28 patients who presented with open wounds with exposed or infected hardware and who were treated with a combination of surgical debridement and negative pressure wound therapy with instillation (NPWTi). Eleven patients were treated for infected spinal hardware, 12 for extremity, and 5 for sternal hardware. Twenty-five of 28 (89%) patients had successful retention or replacement of hardware, with clearance of infection and healed wounds. Original hardware was maintained in 17 of 28 (61%) patients. In 11 patients, original hardware was removed, with subsequent replacement in eight of those patients after a clean wound was achieved. Average time to definitive closure was 12.6 days. Average follow-up was 135 days. This series supports NPWTi as an effective adjunct therapy to help expeditiously eradicate hardware infection, allowing for hardware retention.
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Desbridamiento/instrumentación , Terapia de Presión Negativa para Heridas/instrumentación , Infección de la Herida Quirúrgica/terapia , Irrigación Terapéutica/métodos , Cicatrización de Heridas , Adulto , Anciano , Diseño de Equipo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: To compare targeted muscle reinnervation (TMR) to "standard treatment" of neuroma excision and burying into muscle for postamputation pain. SUMMARY BACKGROUND DATA: To date, no intervention is consistently effective for neuroma-related residual limb or phantom limb pain (PLP). TMR is a nerve transfer procedure developed for prosthesis control, incidentally found to improve postamputation pain. METHODS: A prospective, randomized clinical trial was conducted. 28 amputees with chronic pain were assigned to standard treatment or TMR. Primary outcome was change between pre- and postoperative numerical rating scale (NRS, 0-10) pain scores for residual limb pain and PLP at 1 year. Secondary outcomes included NRS for all patients at final follow-up, PROMIS pain scales, neuroma size, and patient function. RESULTS: In intention-to-treat analysis, changes in PLP scores at 1 year were 3.2 versus -0.2 (difference 3.4, adjusted confidence interval (aCI) -0.1 to 6.9, adjusted P = 0.06) for TMR and standard treatment, respectively. Changes in residual limb pain scores were 2.9 versus 0.9 (difference 1.9, aCI -0.5 to 4.4, P = 0.15). In longitudinal mixed model analysis, difference in change scores for PLP was significantly greater in the TMR group compared with standard treatment [mean (aCI) = 3.5 (0.6, 6.3), P = 0.03]. Reduction in residual limb pain was favorable for TMR (P = 0.10). At longest follow-up, including 3 crossover patients, results favored TMR over standard treatment. CONCLUSIONS: In this first surgical RCT for the treatment of postamputation pain in major limb amputees, TMR improved PLP and trended toward improved residual limb pain compared with conventional neurectomy. TRIAL REGISTRATION: NCT02205385 at ClinicalTrials.gov.
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Amputación Quirúrgica/rehabilitación , Amputados/rehabilitación , Músculo Esquelético/inervación , Transferencia de Nervios/métodos , Neuroma/cirugía , Dolor Postoperatorio/cirugía , Miembro Fantasma/cirugía , Adulto , Femenino , Estudios de Seguimiento , Humanos , Masculino , Dimensión del Dolor , Dolor Postoperatorio/diagnóstico , Estudios Prospectivos , Procedimientos de Cirugía Plástica/métodos , Método Simple CiegoRESUMEN
BACKGROUND: We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS: Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS: Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS: Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.
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Muñones de Amputación/inervación , Amputación Quirúrgica/métodos , Amputación Quirúrgica/rehabilitación , Músculo Esquelético/inervación , Neoplasias/cirugía , Transferencia de Nervios/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias Óseas/rehabilitación , Neoplasias Óseas/cirugía , Estudios de Cohortes , Continuidad de la Atención al Paciente , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Neoplasias/rehabilitación , Osteosarcoma/rehabilitación , Osteosarcoma/cirugía , Grupo de Atención al Paciente , Miembro Fantasma/prevención & control , Sarcoma/rehabilitación , Sarcoma/cirugía , Adulto JovenRESUMEN
PURPOSE: To assess the outcomes of treatment with a dermal regeneration template (DRT) in a cohort of combat casualties with severe upper extremity injuries. METHODS: Records of all active duty military patients treated with DRT at our institution between November 2009 and July 2013 were screened. Inclusion criteria were upper extremity open wounds sustained during combat, requiring split-thickness or full-thickness skin grafting for closure. The primary outcome measure was wound healing after the first attempt at definitive treatment (defined as the first application of split-thickness or full-thickness skin graft). Independent variables collected included time from injury to arrival at our facility, mechanism of injury, wound infection, tobacco use, location of wound, number of operative debridements, and patient demographics. RESULTS: A total of 60 patients with 69 wounds met the inclusion criteria. Most wounds were to the wrist or forearm (54%) or fingers (19%). All wounds were heavily contaminated, requiring a mean of 2.5 operative debridements before DRT placement. All wounds treated with full-thickness skin grafting after DRT healed completely without further complication. Split-thickness skin grafting was successful in 96% of patients. CONCLUSIONS: DRT wound dressings are a helpful adjunct in the treatment of contaminated war wounds to the upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
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Traumatismos del Brazo/cirugía , Trasplante de Piel/métodos , Piel Artificial , Traumatismos de los Tejidos Blandos/cirugía , Guerra , Cicatrización de Heridas/fisiología , Adulto , Traumatismos del Brazo/diagnóstico , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Dimensión del Dolor , Cuidados Posoperatorios/métodos , Estudios Retrospectivos , Medición de Riesgo , Traumatismos de los Tejidos Blandos/diagnóstico , Resultado del Tratamiento , Adulto JovenRESUMEN
Introduction Photochemical tissue bonding (PTB) uses visible light to create sutureless, watertight bonds between two apposed tissue surfaces stained with photoactive dye. In phase 1 of this two-phase study, nerve gaps repaired with bonded isografts were superior to sutured isografts. When autograft demand exceeds supply, acellular nerve allograft (ANA) is an alternative although outcomes are typically inferior. This study assesses the efficacy of PTB when used with ANA. Methods Overall 20 male Lewis rats had 15-mm left sciatic nerve gaps repaired using ANA. ANAs were secured using epineurial suture (group 1) or PTB (group 2). Outcomes were assessed using sciatic function index (SFI), gastrocnemius muscle mass retention, and nerve histomorphometry. Historical controls from phase 1 were used to compare the performance of ANA with isograft. Statistical analysis was performed using analysis of variance and Bonferroni all-pairs comparison. Results All ANAs had signs of successful regeneration. Mean values for SFI, muscle mass retention, nerve fiber diameter, axon diameter, and myelin thickness were not significantly different between ANA + suture and ANA + PTB. On comparative analysis, ANA + suture performed significantly worse than isograft + suture from phase 1. However, ANA + PTB was statistically comparable to isograft + suture, the current standard of care. Conclusion Previously reported advantages of PTB versus suture appear to be reduced when applied to ANA. The lack of Schwann cells and neurotrophic factors may be responsible. PTB may improve ANA performance to an extent, where they are equivalent to autograft. This may have important clinical implications when injuries preclude the use of autograft.
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Regeneración Nerviosa/fisiología , Regeneración Nerviosa/efectos de la radiación , Procesos Fotoquímicos , Nervio Ciático/lesiones , Nervio Ciático/trasplante , Técnicas de Cierre de Heridas , Animales , Modelos Animales de Enfermedad , Colorantes Fluorescentes , Masculino , Músculo Esquelético/inervación , Ratas , Ratas Endogámicas Lew , Recuperación de la Función , Nervio Ciático/patología , Nervio Ciático/efectos de la radiación , Cicatrización de Heridas/fisiología , Cicatrización de Heridas/efectos de la radiaciónRESUMEN
Anterolateral thigh (ALT) free flaps can result in donor site wounds that cannot be closed directly, requiring immediate or delayed split-thickness skin grafting. The use of skin grafts for such wounds can impose postoperative activity restrictions and additional wound morbidity. The purpose of the study was to investigate the efficacy of continuous external tissue expander (CETE) in achieving staged direct closure of these wounds. Outcomes of 20 ALT free flap cases with flap widths up to 15 cm treated with CETE were retrospectively reviewed. Closure of the thigh wounds was achieved in 19 cases with an average expansion time of 9.6 days. The use of a CETE device was effective in achieving staged direct (tertiary) closure and avoiding skin grafting, which further decreased donor site morbidity of large ALT free flap reconstructions.
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Colgajos Tisulares Libres/trasplante , Muslo/cirugía , Expansión de Tejido/métodos , Técnicas de Cierre de Heridas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Expansión de Tejido/instrumentación , Dispositivos de Expansión TisularRESUMEN
First described in 1924, necrotizing fasciitis (NF) is a rapidly progressing, severe suppurative infection of the superficial fascia, often associated with vascular thrombosis and necrosis of the overlying skin. Despite advances in medical therapy, the mortality remains high, with rates exceeding 25 to 50% in some studies. Early diagnosis and treatment is paramount in the management of this serious infection and should include wide surgical debridement and drainage of all necrotic tissues, coupled with aggressive parenteral antibiotics. This infectious process has been commonly associated with traumatic events in patients with compromised immune systems, diabetes, chronic steroid use, and alcoholism. The common microbacterial organisms associated with necrotizing fasciitis include Streptococcus pyogenes and Staphylococcus aureus and less commonly, facultative and anaerobic microorganisms. Most cases typically present in the extremities, trunk, and/or groin regions. Although this virulent soft tissue infection can occur within the face and neck areas, cases of isolated periorbital NF have been relatively uncommon. However, head and neck cases of NF have had high associated morbidity and mortality rates. In recent publications, the reported mortality rate for isolated periorbital NF was not insignificant, ranging from 8.5 to 12.5%. The prognosis, morbidity, and mortality rates will be greatly increased in those patients who present late in the infectious phase, have a delay in diagnosis and/or treatment, or who demonstrate extension of this virulent infection into the face, cervical, or sternal/mediastinal regions. An aggressive multimodal approach is required in treating periorbital necrotizing infection, with the main tenant remaining wide and adequate surgical debridement of affected tissues. This difficult clinical situation can create a subsequent challenge with respect to achieving good functional and cosmetic outcomes in those patients with periorbital NF. Delayed reconstruction of the eyelids with skin grafts and/or facial flaps is often required to avoid late complications such as cicatricial lid retraction, lid malposition, exposure keratopathy, and potential loss of vision. We describe a patient who presented to a military combat hospital with a virulent periorbital soft tissue infection. We have outlined his treatment course from the initial presentation through definitive reconstruction.
Asunto(s)
Fascitis Necrotizante/cirugía , Hospitales Militares/organización & administración , Quirófanos/organización & administración , Órbita/patología , Campaña Afgana 2001- , Afganistán , Desbridamiento , Humanos , Masculino , Persona de Mediana Edad , Trasplante de PielRESUMEN
Recent military operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) have led to further refinements of the military medical system's ability to provide advanced surgical care. The deployment of a global trauma care system has directly contributed to improved combat casualty survival rates. As a consequence of improved survivorship, a high-volume patient population of individuals having challenging multiple extremity injuries/amputations has presented to military treatment facilities. These patients present with unique mixed pattern blast injuries. Blast injuries incorporate multiple mechanisms of injury including penetrating fragmentary injury, blunt force trauma, flash burn, and overpressure wave damage. These complex injuries have furthered refinements in traditional reconstruction and facilitated early application of regenerative medicine therapies. This article summarizes information presented at the inaugural Garry Brody, MD Family Invited Lectureship presented at the 63rd California Society of Plastic Surgeons Annual.
Asunto(s)
Traumatismos del Brazo/cirugía , Traumatismos por Explosión/cirugía , Traumatismos de la Pierna/cirugía , Medicina Militar/métodos , Personal Militar , Traumatismo Múltiple/cirugía , Procedimientos de Cirugía Plástica/métodos , Humanos , Recuperación del Miembro , Colgajos Quirúrgicos , Estados UnidosRESUMEN
Ectopic banking of amputated parts is a recognized technique for delayed replantation of an amputated part when the amputation stump will not permit immediate replantation. This is conventionally performed with the intent of transferring the injured part back to its anatomic position when the amputation stump is more appropriate for replantation. Current warfare conditions have led to a commonly encountered military trauma injury pattern of multiple extremity amputations with protected trunk and core structures. This pattern poses many challenges, including the limit or absence of donor sites for immediate or delayed flap reconstructive procedures. We describe a case in which we ectopically banked the great toe of an amputated lower extremity for delayed thumb reconstruction.
Asunto(s)
Amputación Traumática/cirugía , Procedimientos de Cirugía Plástica/métodos , Pulgar/cirugía , Bancos de Tejidos , Dedos del Pie/trasplante , Adulto , Traumatismos por Explosión/diagnóstico , Traumatismos por Explosión/cirugía , Traumatismos de los Dedos/diagnóstico , Traumatismos de los Dedos/cirugía , Estudios de Seguimiento , Humanos , Puntaje de Gravedad del Traumatismo , Masculino , Personal Militar , Traumatismo Múltiple/diagnóstico , Traumatismo Múltiple/cirugía , Recuperación de la Función , Reimplantación/métodos , Medición de Riesgo , Pulgar/lesiones , Dedos del Pie/cirugía , Resultado del Tratamiento , Cicatrización de Heridas/fisiologíaRESUMEN
Background: Neuropathic pain following nerve injury can be debilitating and negatively impact quality of life. Targeted muscle reinnervation (TMR) is an efficacious technique for the management of neuropathic pain. However, this technique may be unequally available for many geographical locations. Therefore, the aim of this study was to evaluate the association between Area Deprivation Index (ADI) and preoperative pain in patients undergoing TMR for treatment of neuropathic pain. Methods: Patients who underwent TMR for neuropathic pain in the lower and upper extremities were prospectively enrolled at our tertiary care clinic. A chart review was conducted to obtain socioeconomic, surgery, and comorbidity parameters. Preoperative pain scores (0-10 pain score index), and the ADI, reflecting deprivation status on a 0-100 scale, were collected. Results: A total of 162 patients from 13 different states were included, of which 119 were amputees (74%). The median ADI was 25 (IQR: 16-41) and the median preoperative pain score was 6 (IQR: 5-8). A higher ADI was independently associated with higher preoperative pain. The time interval from nerve injury to TMR was not associated with ADI. Conclusions: Patients undergoing surgical treatment of neuropathic pain from more socially deprived settings have increased pain experience upon initial evaluation, despite having similar time from nerve injury or amputation to TMR. These findings highlight the importance of identifying patients presenting from socially deprived settings, as this may impact their physical and mental health along with their coping mechanisms, resulting in increased pain.