Technical Strategies and Learning Curve in Robotic-assisted Peripheral Nerve Surgery.

Background: Robotic-assisted peripheral nerve surgery (RASPN) has emerged as a promising advancement in microsurgery, offering enhanced precision and tremor reduction for nerve coaptations. This study investigated the largest published patient collective in RASPN and provided specific technical aspects, operative setups, and a learning curve. Methods: Data collection involved creating a prospective database that recorded surgical details such as surgery type, duration, nerve coaptation time, and number of stitches. The experienced surgeon first underwent a 12-hour training program utilizing the Symani robot system in combination with optical magnification tools before using the system clinically. Results: The study included 19 patients who underwent robot-assisted peripheral nerve reconstruction. The cohort included six men (31.6%) and 13 women (68.4%), with an average age of 53.8 ± 18.4 years. The procedures included nerve transfers, targeted muscle reinnervation, neurotized free flaps, and autologous nerve grafts. Learning curve analysis revealed no significant reduction in time per stitch over the initial nine coaptations (4.9 ±â€…0.5 min) compared with the last 10 coaptations (5.5 ±â€…1.5 min). Conclusions: The learning curve for RASPN was compared with early experiences with other surgical robots, emphasizing the importance of surgical proficiency and assistant training. Obstacles such as instrument grip strength and blood clot formation were highlighted, and suggestions for future advancements were proposed. RASPN presents an exciting opportunity to enhance precision; however, ongoing research and optimization are necessary to fully harness its benefits.

Resection arthroplasty versus dual mobility prosthesis in the treatment of trapeziometacarpal joint osteoarthritis: A 3 year non-randomized prospective study.

Purpose: Resection arthroplasty (RA) is still the most common surgical intervention for the treatment of symptomatic trapeziometacarpal (TMC) joint osteoarthritis. The implantation of a dual mobility prosthesis may represent a joint function preserving alternative. The aim of the presented study is to prospectively compare the outcomes of RA with dual mobility prosthesis. Methods: In this 2-center non-randomized prospective study, we compared results of RA (n = 22) with implantation of a dual mobility prosthesis (n = 49) (Touch®) at a minimum of 3-year follow-up. The patients underwent preoperative assessments and postoperative follow-up at 6 weeks, 3, 6, 12, 24, and 36 months. Comparisons were conducted, covering pain assessment via the visual analogue scale (VAS), thumb range of motion (ROM), pinch and grip strength, as well as functional scores and radiological examinations. Results: The time intervals from surgery until absence of pain on the VAS (3 months: 3 vs 1, p = 0.0001), recovery of ROM in radial (3 months: 33° vs 42°, p = 0.0001), and palmar abduction (3 months: 33° vs 48°, p = 0.0001), were significantly longer for the RA group compared with the prosthesis group. At 3-year follow-up there was no significant difference in absence of pain, ROM and grip strength between both groups. Key pinch strength was significantly weaker in the RA group compared to prosthesis group at 3 months (2.6 kg vs 4.6 kg, p = 0.001), to 3-year follow-up (3.1 kg vs 5.7 kg, p = 0.0001). The final mean DASH (15.5 vs 13.2, p = 0.01) and MHQ scores (78 vs 82, p = 0.01) were significantly better in the prosthesis group. Conclusion: Both techniques show high patient satisfaction in mid-term follow-up. Dual mobility TMC joint arthroplasty seems to be associated with a superior pinch strength and shorter time of recovery as compared to patients after RA.

Inferior long-term Results of a Prospective Randomized Controlled Trial initially demonstrating enhanced Sensory Nerve Recovery using a Chitosan Nerve Tube.

INTRODUCTION: Traumatic peripheral nerve injuries can result in significant functional impairments and long-term sequelae. This study evaluated the long-term outcomes of a chitosan tube implantation protecting the epineural coaptation after peripheral nerve injuries using two different tube versions (V 1.0 and V 2.0 with different wall thickness and resorption characteristics) compared to a control group. The study focused on pain levels, sensory function, and overall functional outcomes. METHODS: Patients who received tube implantation around direct coaptation sites of digital nerves were prospectively randomized and compared to control patients without additional tube protection. Pain levels, sensory function, grip force, and functional scores were assessed at different time points, ranging from three months to five years after the procedure. Furthermore, biodegradation of the tubes was measured via high-resolution MR-neurography (MRN) and categorized. RESULTS: Long-term evaluation revealed that patients with V 1.0 had higher pain levels compared to the control group after five years. They also reported more symptoms of numbness and hypersensitivity. V 2.0 patients exhibited higher pain levels at three months, which did not persist at six months. However, they showed compromised sensory function, with higher values of two-point discrimination compared to V 1.0 and the control group. No differences were found in grip force or functional scores between the groups. MRI displayed remnants of implants even in long-term follow-up. DISCUSSION: The findings suggest potential limitations due to pain increase and impaired sensory function associated with tube implantation in the long term. However, in the short term, the material seemed to have a protective effect (as published previously). The resorption process was not completed at the end of the observation period of five years. This might explain the prolonged scarring and inferior long-term results. Future research should focus on improving tube materials and design to minimize adverse effects and enhance functional outcomes in patients with peripheral nerve injuries.

Comparative analysis of surgical treatment modalities for a popliteal pterygium: a meta-analysis.

INTRODUCTION: Popliteal pterygium syndrome is a rare congenital disorder characterized by orofacial, cutaneous, musculoskeletal, and genital anomalies. The popliteal pterygium (PP) affects ambulation due to severe knee flexion contracture and equinovarus deformities. Surgical treatment aims to correct these deformities while preserving limb sensibility. However, due to its rarity, surgical guidelines are lacking. MATERIALS AND METHODS: A meta-analysis according to PRISMA guidelines was conducted to summarize and compare surgical methods for PP. 183 paper were identified in PubMed and data from 32 articles were analyzed, including patient demographics, treatment modalities (Ilizarov fixator, femoral osteotomy, skin/soft tissue procedures, hamstring release, nerve surgery, and amputation), pre- and post-operative abilities to walk, knee joint parameters, complications, and recurrent contractions. RESULTS: Among 58 patients (87 limbs), Ilizarov fixator demonstrated improved knee and ankle mobility postoperatively, but showed a relatively high surgical session count and complication rates. Femoral osteotomy achieved successful knee posture correction with fewer sessions and no complications. Isolated skin/soft tissue procedures improved flexion contracture and mobility, though they required several procedures. Hamstring release achieved notable contracture reduction but also necessitated multiple interventions. Nerve surgery and amputation had limited data, warranting further investigation. CONCLUSION: The management of PP demands a comprehensive approach, considering individual patient characteristics and treatment outcomes. While different surgical modalities offer distinct benefits, a classification or guideline to treat this deformity is still lacking. Further research is essential to validate findings, refine treatment approaches, and enhance the quality of life for individuals with PP.

Fibrin Glue Coating Limits Scar Tissue Formation around Peripheral Nerves.

Scar tissue formation presents a significant barrier to peripheral nerve recovery in clinical practice. While different experimental methods have been described, there is no clinically available gold standard for its prevention. This study aims to determine the potential of fibrin glue (FG) to limit scarring around peripheral nerves. Thirty rats were divided into three groups: glutaraldehyde-induced sciatic nerve injury treated with FG (GA + FG), sciatic nerve injury with no treatment (GA), and no sciatic nerve injury (Sham). Neural regeneration was assessed with weekly measurements of the visual static sciatic index as a parameter for sciatic nerve function across a 12-week period. After 12 weeks, qualitative and quantitative histological analysis of scar tissue formation was performed. Furthermore, histomorphometric analysis and wet muscle weight analysis were performed after the postoperative observation period. The GA + FG group showed a faster functional recovery (6 versus 9 weeks) compared to the GA group. The FG-treated group showed significantly lower perineural scar tissue formation and significantly higher fiber density, myelin thickness, axon thickness, and myelinated fiber thickness than the GA group. A significantly higher wet muscle weight ratio of the tibialis anterior muscle was found in the GA + FG group compared to the GA group. Our results suggest that applying FG to injured nerves is a promising scar tissue prevention strategy associated with improved regeneration both at the microscopic and at the functional level. Our results can serve as a platform for innovation in the field of perineural regeneration with immense clinical potential.

[Bionic Surgery Meets Bionic Reconstruction - First In-human use of Robotic Microsurgery in Targeted Muscle Reinnervation]. / Bionische Chirurgie trifft Bionische Rekonstruktion ­ erstes in-human Projekt von robotischer Mikrochirurgie zur Targeted Muscle Reinnervation.

Robotic microsurgery is an emerging field in reconstructive surgery, which provides benefits such as improved precision, optimal ergonomics, and reduced tremors. However, only a few robotic platforms are available for performing microsurgical procedures, and successful nerve coaptation is still a challenge. Targeted muscle reinnervation (TMR) is an innovative reconstructive procedure that rewires multiple nerves to remnant stump muscles, thereby reducing neuroma and phantom limb pain and improving the control of bionic prostheses. The precision of surgical techniques is critical in reducing axonal sprouting around the coaptation site to minimise the potential for neuroma formation. This study reports the first use of a microsurgical robotic platform for multiple nerve transfers in a patient undergoing TMR for bionic extremity reconstruction. The Symani robotic platform, combined with external microscope magnification, was successfully used, and precise handling of nerve tissue and coaptation was easily feasible even in anatomically challenging environments. While the precision and stability offered by robotic assistance may be especially useful for nerve surgery, the high economic costs of robotic microsurgery remain a major challenge for current healthcare systems. In conclusion, this study demonstrated the feasibility of using a robotic microsurgical platform for nerve surgery and transfers, where precise handling of tissue is crucial and limited space is available. Future studies will explore the full potential of robotic microsurgery in the future.

Revealing digital nerve lesions-A comprehensive analysis of 2084 cases of a specialized center.

BACKGROUND: Finger nerve injuries have a significant impact on hand function and can result in reduced sensation, pain and impaired coordination. The socioeconomic implications of these injuries include decreased workplace productivity, reduced earning potential, and financial burdens associated with long-term medical treatment and rehabilitation. However, there is a lack of comprehensive literature regarding the incidence, mechanisms, and associated injuries of finger nerve lesions. METHODS: A retrospective analysis was conducted on patients treated at our institution from January 2012 to July 2020. Cases of peripheral finger nerve lesions were identified using the digital hospital information system and ICD-10 Classification. Exclusion criteria included injuries to the median nerve at the carpal tunnel level or superficial branch of the radial nerve. Data were collected using a pseudonymized approach, and statistical analyses were performed using SPSS Statistics (Version 27). RESULTS: A total of 2089 finger nerve lesions were analyzed, with a majority of cases occurring in men. Most injuries97.4 % were caused by trauma, predominantly cut/tear injuries. Isolated finger nerve injuries were more common than multiple nerve injuries, with the index finger being the most frequently affected. Concomitant tendon and vascular injuries were observed in a significant proportion51.7 % of cases. Surgical management included direct nerve coaptation, interposition grafting and neurolysis. DISCUSSION: Finger nerve injuries are the most prevalent type of nerve injury, often resulting from small lacerations. These injuries have substantial societal costs and can lead to prolonged sick leave. Understanding the epidemiology and etiology of finger nerve injuries is crucial for implementing effective preventive measures. Accompanying tendon injuries and the anatomical location of the nerve lesions can impact sensory recovery and treatment outcomes. Proper management of peripheral finger nerve lesions is essential for optimizing functional outcomes and minimizing the impact on daily activities. Treatment options should be tailored to the severity and underlying cause of the nerve injury.

[Nerve Transfers in Peripheral Nerve Lesions]. / Nerventransfers bei peripheren Nervenläsionen.

BACKGROUND: Lesions of peripheral nerves of the upper extremities often lead to persistent, serious limitations in motor function and sensory perception. Affected patients suffer from both private and professional restrictions associated with long-term physical, psychological and socioeconomic consequences. INDICATION: An early indication for a nerve transfer shortens the reinnervation distance and improves the growing of motor and sensory axons into the target organ to facilitate early mobility and sensitivity. When planning the timepoint of the surgical procedure, the distance to be covered by reinnervation as well as the morbidities of donor nerves must be considered individually. RESULTS: Nerve transfers can achieve earlier and safer reinnervation to improve motor and sensory functions after nerve injuries in the upper extremity.

Ultrasound-An Easy Available and Useful Point-of-Care Adjunct for Clinical Decision-Making in Hand Infections: Review of the Literature and a Case Series.

ABSTRACT: Initial findings of hand infections warrant a thorough treatment strategy depending on the progress of the infection. The decision for surgical treatment can be unclear. Searching to improve the quality of diagnostics, we reviewed the literature regarding the use of point-of-care ultrasound (PCUS) in hand infections and analyzed patients undergoing decision-making with PCUS. We searched PubMed, Scopus, Cochrane Register, and Google Scholar for the use of PCUS in therapy planning in infections of the hand. In addition, we screened our patients from July 1, 2020, to November 30, 2020, to validate the potential benefit of ultrasound examination in suspected hand infections. We evaluated initial clinical examinations versus blinded sonographic assessments in the context of correct decision to proceed with surgery or conservative treatment. Two thousand forty-eight studies within the topic were identified, but only 9 studies were found eligible to be included with a total of 88 patients. The studies illustrate that ultrasound can be performed on all patients, including children and pregnant women, and can be performed in a timely manner. In our retrospective analysis of 20 patients with suspected hand infection, the clinical and ultrasound assessment led to surgery in 13 cases. Of those 13 patients, 7 revealed intraoperative pus. By retrospective assessment of solely the ultrasound images, surgery would have been indicated in 9 cases, including all 7 cases with intraoperative pus. Clinical examination and ultrasound can help in detecting infections of the hand. Ultrasound examination, however, seems to yield a lower false-positive rate than clinical examination. Ultrasound could be a valuable addition to clinical examination.

Shielding the Nerve: A Systematic Review of Nerve Wrapping to Prevent Adhesions in the Rat Sciatic Nerve Model.

BACKGROUND: Peripheral nerve pathology is frequently encountered in clinical practice among peripheral nerve and extremity surgeons. One major factor limiting nerve regeneration and possibly leading to revision surgeries is the development of traumatic or postoperative adhesions and scarring around nerves. In experimental models, different materials have been studied to limit scar tissue formation when wrapped around nerves. METHODS: A systematic review of studies describing nerve-wrapping materials in a non-transectional rat sciatic nerve model was performed following the PRISMA guidelines. Literature describing nerve-wrapping methods for the prevention of peripheral nerve scarring in rat sciatic nerve models was identified using PubMed and Web of Science, scanned for relevance and analyzed. RESULTS: A total of 15 original articles describing 23 different materials or material combinations for nerve wrapping were included. The heterogeneity of the methods used did not allow a meta-analysis, thus, a systematic review was performed. Out of 28 intervention groups, 21 demonstrated a preventive effect on scar tissue formation in at least one qualitative or quantitative assessment method. CONCLUSIONS: The analyzed literature describes a variety of materials from different origins to limit peripheral nerve scarring and adhesions. Thus, a scar-preventive effect by wrapping peripheral nerves as adhesion prophylaxis seems likely. However, a quantitative comparison of the studies to identify the optimal material or technique is not possible with the diversity of used models and study designs. Therefore, further research needs to be performed to identify the optimal nerve wraps to be used routinely in clinical practice.

Improving outcomes in traumatic peripheral nerve injuries to the upper extremity.

Peripheral nerve lesions of the upper extremity are common and are associated with devastating limitations for the patient. Rapid and accurate diagnosis of the lesion by electroneurography, neurosonography, or even MR neurography is important for treatment planning. There are different therapeutic approaches, which may show individual differences depending on the injured nerve. If a primary nerve repair is not possible, several strategies exist to bridge the gap. These may include autologous nerve grafts, bioartificial nerve conduits, or acellular nerve allografts. Tendon and nerve transfers are also of major importance in the treatment of nerve lesions in particular with long regeneration distances. As a secondary reconstruction, in addition to tendon transfers, there is also the option for free functional muscle transfer. In amputations, the prevention of neuroma is of great importance, for which different strategies exist, such as target muscle reinnervation, regenerative peripheral nerve interface, or neurotized flaps. In this article, we give an overview of the latest methods for the therapy of peripheral nerve lesions.

Mechanisms, interventions at risk and clinical presentation of iatrogenic nerve lesions in trauma patients.

BACKGROUND: Iatrogenic nerve lesions during surgical interventions are avoidable complications that may cause severe functional impairment. Hereby, awareness of physicians and knowledge of structures and interventions at risk is of utmost importance for prevention. As current literature is scarce, we evaluated all patients treated surgically due to peripheral nerve injuries in our specialized nerve center for the presence of iatrogenic nerve lesions. METHODS: We evaluated a total of 5026 patients with peripheral nerve injuries treated over a time period of 8 years in our facility for the prevalence of iatrogenic nerve injuries, their clinical presentations, time to treatment, mechanisms and intraoperative findings on nerve continuity. RESULTS: A total of 360 (6.1%) patients had an iatrogenic cause resulting in 380 injured nerves. 76.6% of these lesions affected the main branch of the injured nerve, which were mainly the radial (30.5%), peroneal (13.7%) and median nerve (10.3%). After a mean delay of 237 ± 344 days, patients presented 23.2% with a motor and 27.9% with a mixed sensory and motor deficit. 72.6% of lesions were in-continuity lesions. Main interventions at risk are displayed for every nerve, frequently concerning osteosyntheses but also patient positioning and anesthesiologic interventions. DISCUSSION: Awareness of major surgical complications such as iatrogenic nerve injuries is important for surgeons. An often-seen trivialization or "watch and wait" strategy results in a huge delay for starting an adequate therapy. The high number of in-continuity lesions mainly in close proximity to osteosyntheses makes diagnosis and treatment planning a delicate challenge, especially due to the varying clinical presentations we found. Diagnostics and therapy should therefore be performed as early as possible in specialized centers capable of performing nerve repair as well as salvage therapies.

Avoiding scar tissue formation of peripheral nerves with the help of an acellular collagen matrix.

INTRODUCTION: Extensive scar tissue formation after peripheral nerve injury or surgery is a common problem. To avoid perineural scarring, implanting a mechanical barrier protecting the nerve from inflammation processes in the perineural environment has shown promising results for functional recovery. This study investigates the potential of an acellular collagen-elastin matrix wrapped around a peripheral nerve after induction of scar tissue formation. MATERIALS AND METHODS: In the present study, 30 Lewis rats were separated into three groups and sciatic nerve scarring was induced with 2.5% glutaraldehyde (GA-CM) or 2.5% glutaraldehyde with a supplemental FDA-approved acellular collagen-elastin matrix application (GA+CM). Additionally, a sham group was included for control. Nerve regeneration was assessed by functional analysis using the Visual Statisc Sciatic Index (SSI) and MR neurography during the 12-week regeneration period. Histological and histomorphometry analysis were performed to evaluate the degree of postoperative scar tissue formation. RESULTS: Histological analysis showed an extensive scar tissue formation for GA-CM. Connective tissue ratio was significantly (p < 0.009) reduced for GA+CM (1.347 ± 0.017) compared to GA-CM (1.518 ± 0.057). Similarly, compared to GA+CM, MR-Neurography revealed extensive scar tissue formation for GA-CM with a direct connection between nerve and paraneural environment. Distal to the injury site, quantitative analysis presented significantly higher axon density (p = 0.0145), thicker axon diameter (p = 0.0002) and thicker myelinated fiber thickness (p = 0.0008) for GA+CM compared to GA-CM. Evaluation of functional recovery revealed a significantly faster regeneration for GA+CM. CONCLUSION: The supplemental application of an acellular collagen-elastin matrix showed beneficial effects in histological, radiological, and functional analysis. Therefore, applying a collagen-elastin matrix around the nerve after peripheral nerve injury or surgery may have beneficial effects on preventing scar tissue formation in the long run. This represents a feasible approach to avoid scar tissue formation in peripheral nerve surgery.

The Surgical Restoration of Arm and Hand Function in Tetraplegic Patients.

BACKGROUND: There are approximately 140 000 people in Germany with spinal cord injury, with approximately 2400 new patients each year. Cervical spinal cord injuries cause, to varying degrees, weakness and impairment of everyday activities of the limbs (tetraparesis, tetraplegia). METHODS: This review is based on relevant publications retrieved by a selective search of the literature. RESULTS: From among 330 initially screened publications, 40 were included and analyzed. Muscle and tendon transfers, tenodeses, and joint stabilizations yielded reliable functional improvement of the upper limb. Tendon transfers improved the strength of elbow extension from M0 to an average of M3.3 (BMRC) and grip strength to approximately 2 kg. In the long term, 17-20% of strength is lost after active tendon transfers and slightly more after passive ones. Nerve transfers improved strength to M3 or M4 in over 80% of cases, with the best results overall in patients under 25 years of age who underwent early surgery (within 6 months of the accident). Combined procedures in a single operation have been found to be advantageous compared to the traditional multistep approach. Nerve transfers from intact fascicles at segmental levels above that of the spinal cord lesion have been found to be a valuable addition to the established varieties of muscle and tendon transfer. The reported long-term patient satisfaction is generally high. CONCLUSION: Modern techniques of hand surgery can help suitably selected tetraparetic and tetraplegic patients regain the use of their upper limbs. Competent interdisciplinary counseling about these surgical options should be offered as early as possible to all affected persons as an integral part of their treatment plan.

Peripheral nerve injuries in children-prevalence, mechanisms and concomitant injuries: a major trauma center's experience.

BACKGROUND: Peripheral nerve injuries are severe conditions with potential lifelong impairment, which is especially meaningful for the pediatric population. Knowledge on prevalence, injury mechanisms and concomitant injuries is, therefore, of utmost importance to increase clinician awareness and enable early diagnosis and treatment. As current literature on pediatric nerve lesions and concomitant injuries is scarce, we aimed to analyze all details of our patient population. METHODS: A total of 110 667 patients treated at our level 1 trauma center from 2012 to 2021 were evaluated for pediatric peripheral nerve injuries, causes, concomitant injuries and assessed for lesion classification (in continuity, partial lesion, dissection) and further relevant intraoperative findings. RESULTS: We found 5026 patients of all ages with peripheral nerve lesions, whereof 288 were pediatric, resulting in a prevalence of 5.7% of pediatric patients with nerve injuries. Mean age was 12.4 ± 4.6 years. Most common lesions were digital nerves (48.2%), followed by median (14.9%), ulnar (14.6%), radial (8.8%), peroneal nerve (5.2%) and brachial plexus injuries (2.1%). Of all pediatric nerve injuries, 3.8% were iatrogenic, only 30.2% had preserved continuity and 47.3% a concomitant vessel injury. Fractures were accompanied in 22.6%. DISCUSSION: We observed that a large proportion of injures had complete transections, often accompanied by concomitant vessel injuries especially in distally located injuries, highlighting the importance of early surgical exploration. Radial, ulnar and lower extremity nerve injuries were often associated with fractures. Early surgical nerve repair is key to improve motor and sensory outcomes. Knowledge on mechanisms and concomitant injuries facilitates timely diagnosis and treatment, thereby potentially preventing lifelong impairment.

Benefit of Adjuvant Mesenchymal Stem Cell Transplantation to Critical-Sized Peripheral Nerve Defect Repair: A Systematic Review and Meta-Analysis of Preclinical Studies.

Critically sized nerve defects cause devastating life-long disabilities and require interposition for reconstruction. Additional local application of mesenchymal stem cells (MSCs) is considered promising to enhance peripheral nerve regeneration. To better understand the role of MSCs in peripheral nerve reconstruction, we performed a systematic review and meta-analysis of the effects of MSCs on critically sized segment nerve defects in preclinical studies. 5146 articles were screened following PRISMA guidelines using PubMed and Web of Science. A total of 27 preclinical studies (n = 722 rats) were included in the meta-analysis. The mean difference or the standardized mean difference with 95% confidence intervals for motor function, conduction velocity, and histomorphological parameters of nerve regeneration, as well as the degree of muscle atrophy, was compared in rats with critically sized defects and autologous nerve reconstruction treated with or without MSCs. The co-transplantation of MSCs increased the sciatic functional index (3.93, 95% CI 2.62 to 5.24, p < 0.00001) and nerve conduction velocity recovery (1.49, 95% CI 1.13 to 1.84, p = 0.009), decreased the atrophy of targeted muscles (gastrocnemius: 0.63, 95% CI 0.29 to 0.97 p = 0.004; triceps surae: 0.08, 95% CI 0.06 to 0.10 p = 0.71), and promoted the regeneration of injured axons (axon number: 1.10, 95% CI 0.78 to 1.42, p < 0.00001; myelin sheath thickness: 0.15, 95% CI 0.12 to 0.17, p = 0.28). Reconstruction of critically sized peripheral nerve defects is often hindered by impaired postoperative regeneration, especially in defects that require an autologous nerve graft. This meta-analysis indicates that additional application of MSC can enhance postoperative peripheral nerve regeneration in rats. Based on the promising results in vivo experiments, further studies are needed to demonstrate potential clinical benefits.

Hopeless Neuroma-The Neurotized Free Flap Tissue Augmentation as Salvage Therapy-A Concept and Clinical Demonstration.

Therapy-resistant neuroma pain is a devastating condition for patients and surgeons. Although various methods are described to surgically deal with neuromas, some discontinuity and stump neuroma therapies have anatomical limitations. It is widely known that a neurotizable target for axon ingrowth is beneficial for dealing with neuromas. The nerve needs "something to do". Furthermore, sufficient soft tissue coverage plays a major role in sufficient neuroma therapy. We aimed, therefore, to demonstrate our approach for therapy of resistant neuromas with insufficient tissue coverage using free flaps, which are sensory neurotized via anatomical constant branches. The central idea is to provide a new target, a new "to do" for the painful mislead axons, as well as an augmentation of deficient soft tissues. As indication is key, we furthermore demonstrate clinical cases and common neurotizable workhorse flaps.

Effect of Surgical Release of Entrapped Peripheral Nerves in Sensorimotor Diabetic Neuropathy on Pain and Sensory Dysfunction-Study Protocol of a Prospective, Controlled Clinical Trial.

BACKGROUND: Nerve entrapment has been hypothesized to contribute to the multicausal etiology of axonopathy in sensorimotor diabetic neuropathy. Targeted surgical decompression reduces external strain on the affected nerve and, therefore, may alleviate symptoms, including pain and sensory dysfunction. However, its therapeutic value in this cohort remains unclear. AIM: Quantifying the treatment effect of targeted lower extremity nerve decompression in patients with preexisting painful sensorimotor diabetic neuropathy and nerve entrapment on pain intensity, sensory function, motor function, and neural signal conduction. STUDY DESIGN: This prospective, controlled trial studies 40 patients suffering from bilateral therapy-refractory, painful (n = 20, visual analogue scale, VAS ≥ 5) or painless (n = 20, VAS = 0) sensorimotor diabetic neuropathy with clinical and/or radiologic signs of focal lower extremity nerve compression who underwent unilateral surgical nerve decompression of the common peroneal and the tibial nerve. Tissue biopsies will be analyzed to explore perineural tissue remodeling in correlation with intraoperatively measured nerve compression pressure. Effect size on symptoms including pain intensity, light touch threshold, static and moving two-point discrimination, target muscle force, and nerve conduction velocity will be quantified 3, 6, and 12 months postoperatively, and compared (1) to the preoperative values and (2) to the contralateral lower extremity that continues non-operative management. CLINICAL SIGNIFICANCE: Targeted surgical release may alleviate mechanical strain on entrapped lower extremity nerves and thereby potentially improve pain and sensory dysfunction in a subset of patients suffering from diabetic neuropathy. This trial aims to shed light on these patients that potentially benefit from screening for lower extremity nerve entrapment, as typical symptoms of entrapment might be erroneously attributed to neuropathy only, thereby preventing adequate treatment.

Objective Burn Scar Assessment in Clinical Practice Using the Cutometer©: Introduction and Validation of a Standardized Measurement Protocol.

An objective burn scar assessment is essential to informed therapeutic decision-making and to monitor scar development over time. However, widely employed scar rating scales show poor inter-rater reliability. For this study we developed a standardized measurement protocol for the Cutometer© applicable for objective burn scar assessment in everyday clinical practice. We developed a measurement protocol for the Cutometer© MPA 580 including a scar site relocation technique based on anatomical landmarks. The protocol emerged through several steps: Identifying key factors for valid and reliable measurements, preliminary testing, specification of technical details, refining the protocol and final testing. Consecutively, the protocol was validated for inter-rater reliability by assessing 34 burn scars in 17 patients by four clinicians and computing an Intra-class Correlation Coefficient (ICC). Parameter R0, representing scar pliability, was identified as the best suited output parameter yielding excellent inter-rater reliability for average measures (ICC 0.92 [95% CI 0.86; 0.96]) and acceptable reliability for single measures (ICC: 0.74 [0.61; 0.84]). The pressure applied on the measuring probe was identified as an influential confounding factor for reliable measurements. Rater gender did not influence reliability of measurements. The introduced standardized measurement protocol for the Cutometer© MPA 580 enables an objective and reliable burn scar assessment for clinical as well as research purposes.

Modern MRI Diagnostics of Upper-Extremity-Related Nerve Injuries-A Prospective Multi-Center Study Protocol for Diagnostics and Follow Up of Peripheral Nerve Injuries.

(1) Background: Peripheral nerve injuries are severe injuries with potentially devastating impairment of extremity function. Correct and early diagnosis as well as regular regeneration observation is of utmost importance for individualized reconstruction and the best possible results. Currently, diagnoses and follow-up examinations are based on clinical examinations supported with electroneurography, which often causes delays in treatment and can result in impaired healing. However, there is currently no diagnostic device that can reliably correlate the anatomic-pathological parameters with the functional-pathological changes initially and during therapy. With new technologies such as MR neurography (MRN), precise visualization of potential nerve damage and visualization of the reinnervation processes is assumed to accelerate clinical decision making and accompaniment of individualized treatment. (2) Methods/Design: This prospective clinical study will examine 60 patients after peripheral nerve lesion aged 18-65 years from trauma timepoint onward. Patients should be observed over a period of 18-24 months with regular clinical examinations, electroneurography, and ultrasound to compare the potential of MRN to current gold-standard diagnostic tools. Furthermore, 20 patients with the same inclusion criteria stated above, with an internal fixation and osteosyntheses of humerus fractures, will be examined to determine the visibility of peripheral nerve structures in close proximity to metal. (3) Discussion: Peripheral nerve injuries are often accompanied with severe, expensive, and long-lasting impairment of extremity function. An early and precise diagnosis of the nerve lesion, as well as the healing course, is crucial to indicate the right therapy as soon as possible to save valuable time for nerve regeneration. Here, new technologies such as MRN aim to visualize nerve injuries on fascicular level, providing not only early diagnosis and therapy decisions, but also providing a precise tool for monitoring of reinnervation processes. As severe injuries of a nerve are often accompanied with bone fractures and internal fixation, we also aim to evaluate the visualization feasibility of nerves in close proximity to metal, and ultimately improve the outcome and extremity function of patients after a peripheral nerve injury.