Partial tibial nerve transfer for iatrogenic peroneal nerve palsy after endovenous laser ablation for varicose veins of the lower extremity: A case report.

Postprocedural peroneal nerve palsy after endovenous laser ablation (EVLA) for varicose veins is rare and is associated with poor functional recovery. There have been no reports using tibial nerve transfer for iatrogenic peroneal nerve palsy after EVLA. Herein, we present a case with peroneal nerve injury after EVLA, which was successfully treated by partial tibial nerve transfer for the first time. A 75-year-old female presented with a right foot drop immediately after EVLA of the lesser saphenous vein. The ankle and toe dorsiflexion had a muscle grade of M0 on the British Medical Research Council muscle scale, without voluntary motor unit action potentials (MUAP) in the tibialis anterior (TA) muscle on the needle electromyography. Three months after the injury, surgical nerve exploration revealed a damaged common peroneal nerve with discoloration and scarring at the fibular head. Intraoperative deep peroneal nerve stimulation confirmed the absence of compound muscle action potentials in the TA. The best functioning motor fascicles of the tibial nerve were transferred to the deep peroneal main trunk involving motor branches of the TA, extensor digitorum longus, and extensor hallucis longus (EHL) through the interosseous membrane. The postoperative course was uneventful, with no complications. After 3 months of surgery, nascent MUAP appeared in the TA. After 24 months, the patient regained the TA and EHL muscle function and ambulation without an ankle-foot orthosis and tibial nerve deficits. Thus, our procedure may serve as an alternative to nerve grafting, tendon transfer, and orthoses for better management of the major neural complications associated with EVLA.

Prognostic value of psoas major muscle density in patients with breast cancer metastases to bone: a retrospective single-center cohort study.

OBJECTIVE: Although sarcopenia is associated with poor prognosis for cancer patients, the relationship between muscle quantity and quality, and prognosis of breast cancer patients with bone metastases is unclear. This study aims to evaluate the association of muscle parameters, muscle area and density, and overall survival (OS) from the diagnosis of bone metastases in breast cancer patients with bone metastases. METHODS: This study retrospectively investigated the prognostic value of muscle area and density in 90 women who were diagnosed with breast cancer with bone metastases between September 2005 and June 2018. We measured psoas major muscle and paravertebral muscle area and density on single axial computed tomography images at the L3 level and subgrouped the patients into higher or lower groups for each muscle measurement, using median values as cutoffs. We evaluated associations between OS and muscle parameters, using a Cox proportional hazards model adjusted by age and prognostic score for bone metastases (modified Katagiri score). RESULTS: Median OS among patients with lower psoas major muscle density (25 months) was significantly shorter than in the higher psoas major muscle density group (61 months; hazard ratio: 1.79, 95% confidence interval: 1.01-3.16, P = 0.045). However, muscle area and paravertebral muscle density were not associated with OS in this setting. CONCLUSION: Lower psoas major muscle density was a predictor of poor prognosis in patients with breast cancer metastases to bone. The association between psoas major muscle density and prognosis allows wider research into interventions that can prevent loss of muscle density.

Nerve-End Capping Treatment with a Polyglycolic Acid Conduit for Rat Sciatic Neuroma: A Preliminary Report.

BACKGROUND: The treatment of painful neuroma remains challenging. Recently, a nerve-end capping technique using a bioabsorbable nerve conduit was newly introduced to treat amputation neuroma. A collagen-coated polyglycolic acid (PGA) conduit has been commercially available for the reconstruction of peripheral nerve defects, yielding successful clinical outcomes. However, no experimental research has been conducted using this PGA nerve conduit as capping device for treating amputation neuroma. The purpose of this study was to investigate nerve-end capping treatment with the PGA conduit in the rat sciatic nerve amputation model, focusing on histological scar formation and neuroinflammation. METHODS: Forty-seven rats were divided into two groups: no capping (transected nerve stump without capping; n = 25) and capping (nerve-end capping with collagen-coated PGA nerve conduit; n = 22). Twelve weeks after sciatic neurectomy, neuropathic pain was evaluated using the autotomy score. Stump neuromas were histologically evaluated or perineural scar and neuroinflammation. RESULTS: While autotomy scores gradually exacerbated in both groups, they were consistently lower in the capping group at 4, 8, and 12 weeks postprocedure. Twelve weeks after surgery, the transected nerve stumps in the no-capping group had formed macroscopic bulbous neuromas strongly adhering to surrounding tissues, whereas they remained wrapped with the PGA nerve conduits loosely adhering to surrounding tissues in the capping group. Histologically, distal axonal fibers were expanded radially and formed neuromas in the no-capping group, while they were terminated within the PGA conduit in the capping group. Perineural scars and neuroinflammation were widely found surrounding the randomly sprouting nerve end in the no-capping group. In capped counterparts, scars and inflammation were limited to closely around the terminated nerve end. CONCLUSION: Nerve-end capping with a collagen-coated PGA conduit after rat sciatic neurectomy might prevent neuroma formation by suppressing perineural scar formation and neuroinflammation around the nerve stump, potentially relieving neuropathic pain.

Low paravertebral muscle mass in patients with bone metastases from lung cancer is associated with poor prognosis.

PURPOSE: Low skeletal muscle mass has been associated with poor prognosis in patients with advanced lung cancer. However, little is known about the relationship between skeletal muscle mass and overall survival in patients with bone metastases from lung cancer. The objective of the present study was to evaluate the prognostic value of low trunk muscle mass in predicting overall survival in these patients. METHODS: The data from 198 patients who were diagnosed with bone metastases from lung cancer from April 2009 to May 2017 were retrospectively reviewed. The areas of the psoas and paravertebral muscles were measured at the level of the third lumbar vertebra on computed tomography scans taken at the time nearest to the diagnosis of bone metastasis. Muscle area was evaluated for male and female cohorts separately using different cutoff points. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival. RESULTS: The overall survival of patients in the lowest quartile for psoas muscle area or paravertebral muscle area was significantly shorter than that of patients above the 25th percentile for muscle area (p < 0.001). Multivariate analyses showed that paravertebral muscle mass (hazard ratio, 1.73; 95% confidence interval, 1.17-2.56; p = 0.006), epidermal growth factor receptor-targeted therapy, and performance status were independent prognostic factors. CONCLUSIONS: Low paravertebral muscle mass was associated with shorter survival, independently of known prognostic factors.

Evaluation of dual release of stromal cell-derived factor-1 and basic fibroblast growth factor with nerve conduit for peripheral nerve regeneration: An experimental study in mice.

BACKGROUND: The development of drug delivery systems has enabled the release of multiple bioactive molecules. The efficacy of nerve conduits coated with dual controlled release of stromal cell-derived factor-1 (SDF-1) and basic fibroblast growth factor (bFGF) for peripheral nerve regeneration was investigated. MATERIALS AND METHODS: Sixty-two C57BL6 mice were used for peripheral nerve regeneration with a nerve conduit (inner diameter, 1 mm, and length, 7 mm) and an autograft. The mice were randomized into five groups based on the different repairs of nerve defects. In the group of repair with conduits alone (n = 9), a 5-mm sciatic nerve defect was repaired by the nerve conduit. In the group of repair with conduits coated with bFGF (n = 10), SDF-1 (n = 10), and SDF-1/bFGF (n = 10), it was repaired by the nerve conduit with bFGF gelatin, SDF-1 gelatin, and SDF-1/bFGF gelatin, respectively. In the group of repair with autografts (n = 10), it was repaired by the resected nerve itself. The functional recovery, nerve regeneration, angiogenesis, and TGF-ß1 gene expression were assessed. RESULTS: In the conduits coated with SDF-1/bFGF group, the mean sciatic functional index value (-88.68 ± 10.64, p = .034) and the axon number (218.8 ± 111.1, p = .049) were significantly higher than the conduit alone group, followed by the autograft group; in addition, numerous CD34-positive cells and micro vessels were observed. TGF-ß1 gene expression relative values in the conduits with SDF-1/bFGF group at 3 days (7.99 ± 5.14, p = .049) significantly increased more than the conduits alone group. CONCLUSION: Nerve conduits coated with dual controlled release of SDF-1 and bFGF promoted peripheral nerve regeneration.

Identification of Ulnar Artery Perforators Using Color Doppler Ultrasonography.

BACKGROUND: The ulnar artery perforator (UAP) flap, which is hairless, thin, and pliable, has been used for the reconstruction of soft tissues from the finger to the elbow. Preoperative planning is essential for a perforator flap surgery, and there are some tests to identify perforators. Color Doppler ultrasonography (US) with a high-frequency transducer helps in detecting decreased flow in smaller vessels, such as perforators. The purpose of this study was to determine the anatomical locations and origins of perforators arising from the ulnar artery using color Doppler US in healthy volunteers. METHODS: Forty forearms of 20 healthy volunteers were included in the study. Perforators arising from the ulnar artery, within 100 mm proximal to the pisiform, were investigated using color Doppler US with a high-frequency transducer. RESULTS: A total of 205 perforators were identified. On comparing the locations in each 20 mm section from the pisiform, the largest number of perforators was 58 (28%), within 20 mm proximal to the pisiform. The axial view demonstrated 44 (21%), 64 (31%), 32 (16%), and 65 (32%) perforators in the radial, ulnar, superficial, and deep aspects of the ulnar artery, respectively. Fifty-two and 28 essential perforators were supplied by the UAPs arising from the superficial and ulnar aspect within 20 mm proximal to the pisiform and between 21 and 40 mm proximal to the pisiform, respectively, while elevating the UAP flap. CONCLUSION: This is the first study to assess the UAP using color Doppler US. Identification of UAP using color Doppler US can be used as a preoperative assessment for reliable elevation of a UAP flap.

Prognostic value of paravertebral muscle density in patients with spinal metastases from gastrointestinal cancer.

PURPOSE: Morphometric analyses have shown that trunk muscle mass and density are associated with mortality in cancer patients. Because of the low incidence of spinal metastasis from gastrointestinal cancer and the limited life expectancy of these patients, few studies have been reported in this population. We evaluated the prognostic value of trunk muscle area and density in predicting overall survival. METHODS: The data from 78 patients with spinal metastases from gastrointestinal cancer, collected from February 2009 to July 2016, were evaluated. Psoas muscle and paravertebral muscle area and density were measured at the L3 level on CT scans taken at the time nearest to the diagnosis of spinal metastasis. Cox proportional hazards analysis was performed to evaluate the factors independently associated with overall survival. RESULTS: The mean patient age was 68.3 years (range, 42-88 years). The overall median survival time was 4.8 months: 2.2 months in the extremely rapid growth group (stomach, biliary tract, and pancreas) and 7.6 months in the rapid growth group (esophagus, liver, and colorectum). Multivariate analyses showed that lower paravertebral muscle density (HR 2.23 [95% CI 1.24-3.99], p = 0.007), extremely rapid growth group, presence of abnormal laboratory data, poor performance status, and chemotherapy after spinal metastasis were independent prognostic factors. CONCLUSIONS: Median overall survival was poor among patients with spinal metastases from gastrointestinal carcinoma, especially among those with gastric, biliary tract, or pancreatic cancer. Lower paravertebral muscle density was an independent poor prognostic factor in patients with spinal metastases from gastrointestinal cancer.

Overall survival and prognostic factors in patients with spinal metastases from lung cancer treated with and without epidermal growth factor receptor tyrosine kinase inhibitors.

BACKGROUND: Evaluation of the prognosis in patients with spinal metastases is important in decision making regarding surgical treatment. The purpose of this study was to investigate overall survival in patients with spinal metastases from lung cancer by histological subtype, and to investigate prognostic factors in patients treated with and without epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). METHODS: The data from 135 patients diagnosed with spinal metastases from lung cancer were retrospectively evaluated. The 88 patients with adenocarcinoma were divided into two groups according to whether the lung cancer was treated with or without EGFR-TKIs-the EGFR-TKI group (n = 43) and the non-EGFR-TKI group (n = 45). RESULTS: The overall median survival time was 11.3 months for those with adenocarcinoma, 5.3 months for squamous cell carcinoma, and 3.9 months for small cell carcinoma. Overall survival in the EGFR-TKI group (median 21.4 months) was significantly longer than in the non-EGFR-TKI group (median 6.1 months). In univariate analysis, poor performance status was a poor prognostic factor in the non-EGFR-TKI group. However, performance status and other variables were not significant prognostic factors in the EGFR-TKI group. CONCLUSIONS: Median overall survival was longer in patients with spinal metastases from lung cancer treated with EGFR-TKIs compared with those treated without EGFR-TKIs. Poor performance status or other prognostic factors were not associated with poor overall survival in the group treated with EGFR-TKIs.

Anatomical Origins of Radial Artery Perforators Evaluated Using Color Doppler Ultrasonography.

Background The radial artery perforator (RAP) flap has been widely used for covering hand and forearm defects, and real-time accurate perforator mapping is important in planning and elevating the perforator flap. The origins of perforators, especially the superficial and ulnar perforators, arising from the radial artery are very important in the elevation of the RAP flap. Recently, color Doppler ultrasonography (US) using a higher frequency transducer has been developed for high-quality detection of lower flow in smaller vessels. This study aimed to identify the anatomical locations and origins of perforators arising from the radial artery using color Doppler US in healthy volunteers. Methods Twenty forearms of 10 volunteers were examined. Results In total, 120 perforators arising from the radial artery were identified 15 cm proximal to the distal wrist crease, with an average of six perforators per forearm. More than half the perforators (n = 72, 60%) were located within 50 mm proximal to the distal wrist crease. Regarding the perforator origins in the axial view, 40 perforators (33%) were located in the radial aspect of the radial artery, 47 (39%) in the ulnar aspect, 15 (13%) in the superficial aspect, and 18 (15%) in the deep aspect. In total, 62 (52%) perforators were located in the superficial and ulnar areas, which are important in nourishing and elevating the RAP flap. Conclusion We are the first to evaluate RAP using color Doppler US. This noninvasive, convenient, and real-time technique could be useful for preoperative planning and reliably elevating the RAP flaps.

Long-term efficacy and safety outcomes of transplantation of induced pluripotent stem cell-derived neurospheres with bioabsorbable nerve conduits for peripheral nerve regeneration in mice.

The induced pluripotent stem cell (iPSc) offers great potential for cell-based therapy in regenerative medicine. We previously developed tissue-engineered bioabsorbable nerve conduits coated with iPSc-derived neurospheres for use in peripheral nerve repair. Here, we examine the long-term efficacy and safety of using nerve conduits with iPSc technology for peripheral nerve repair in mice. The nerve conduit consisted of an outer layer of a poly L-lactide mesh and an inner layer of porous sponge composed of 50% L-lactide and 50% ε-caprolactone. Secondary neurospheres were derived from mouse iPScs, resuspended and cultured within the conduit for 14 days. Conduits were implanted within surgically administered 5-mm defects in the left sciatic nerve of mice (iPSc group; n = 14). The defects in the control group (n = 13) were reconstructed using the nerve conduit alone. At 4, 8, 12, 24 and 48 weeks postsurgery, motor and sensory functional recovery in the iPSc group had improved significantly more than in the control group. At 24 and 48 weeks, histological analysis revealed axonal regeneration in the nerve conduits of both groups. However, axonal regeneration and myelination were significantly enhanced in the iPSc group. No teratomas were identified in the iPSc group at any time point. Therefore, we here demonstrate that bioabsorbable nerve conduits coated with iPSc-derived neurospheres promote enhanced regeneration of peripheral nerves and functional recovery without teratoma formation in the long term. This combination of iPSc technology and bioabsorbable nerve conduits has the potential to be a safe future tool for the treatment of peripheral nerve defects.

Peripheral nerve regeneration by bioabsorbable nerve conduits filled with platelet-rich fibrin.

PURPOSE: To repair peripheral nerve defects and seek alternatives for autografts, nerve conduits with various growth factors and cells have been invented. Few pieces of literature report the effect of nerve conduits plus platelet-rich fibrin (PRF). This study aimed to investigate the effectiveness of nerve conduits filled with PRF. METHODS: The model of a 10 mm sciatic nerve gap in a rat was used to evaluate peripheral nerve regeneration. The thirty rats were randomly divided into one of the following three groups (n = 10 per group). Autogenous nerve grafts (autograft group), conduits filled with phosphate-buffered saline (PBS) (PBS group), or conduits filled with PRF group (PRF group). We assessed motor and sensory functions for the three groups at 4, 8, and 12 weeks postoperatively. In addition, axon numbers were measured 12 weeks after repair of the peripheral nerve gaps. RESULTS: Significant differences in motor function were observed between the autograft group and the other two groups at 12 weeks postoperatively. In the test to evaluate the recovery of sensory function, there were significant differences between the PBS group and the other two groups at all time points. The most axon number was found in the autograft group. The axon number of the PRF group was significantly more extensive than that of the PBS group. CONCLUSIONS: The nerve conduit filled with PRF promoted the axon regeneration of the sciatic nerve and improved sensory function.

Solitary neurolymphomatosis of the brachial plexus mimicking benign nerve sheath tumour: case report.

Neurolymphomatosis typically appears as a diffuse lesion with thickening of the affected nerves on magnetic resonance imaging (MRI). MRI in the present case revealed a well-defined, solitary lesion showing continuity with brachial plexus nerves. Findings including clinical symptoms resembled benign nerve sheath tumour rather than neurolymphomatosis. Intra-operatively, the C8 root was focally swollen, corresponding to a well-circumscribed lesion on MRI. The diagnosis of neurolymphomatosis was obtained only after resection biopsy. Post-operatively, (18)F-fluorodeoxyglucose positron emission tomography proved useful for follow-up evaluation. We offer the first description of the MRI characteristics of brachial plexopathy in neurolymphomatosis, along with the clinical course.

Association between Opioid Requirement and Overall Survival in Patients with Spinal Metastases.

Introduction: Clinical evidence shows that opioid administration in cancer patients is associated with shorter survival. This study explored the impact of opioid requirement on overall survival of patients with spinal metastases. We also evaluated the association between opioid requirement and tumor-related spinal instability. Methods: We retrospectively identified 428 patients who had been diagnosed with spinal metastases from February 2009 to May 2017. Those with an opioid prescription during the first 1 month after the diagnosis were included in this study. Patients given opioids were divided into two groups: the opioid requirement group [≥5 mg oral morphine equivalent (OME)/day] and the nonopioid group (<5 mg OME/day). Spinal instability due to metastases was evaluated using the Spinal Instability Neoplastic Score (SINS). Cox proportional hazards analysis was performed to evaluate the relationship between opioid use and overall survival. Results: The most frequent primary cancer site was the lung, in 159 patients (37%), followed by the breast in 75 (18%) and the prostate in 46 (11%). Multivariate analyses showed that patients who required ≥5 mg OME/day were approximately twofold more likely to die after a spinal metastases diagnosis than those who required <5 mg OME/day (hazard ratio 2.13; 95% confidence interval 1.69-2.67; p<0.001). The SINS was significantly higher in the opioid requirement group than those in the nonopioid group (p<0.001). Conclusions: For patients with spinal metastases, opioid requirement was associated with shorter survival, independently of known prognostic factors. The patients were also more likely to have tumor-related spinal instability than those in the nonopioid group.

Transplantation of induced pluripotent stem cell-derived neurospheres for peripheral nerve repair.

In spite of the extensive research using induced pluripotent stem (iPS) cells, the therapeutic potential of iPS cells in the treatment of peripheral nerve injury is largely unknown. In this study, we repaired peripheral nerve gaps in mice using tissue-engineered bioabsorbable nerve conduits coated with iPS cell-derived neurospheres. The secondary neurospheres derived from mouse iPS cells were suspended in each conduit (4000,000 cells per conduit) and cultured in the conduit in three-dimensional (3D) culture for 14 days. We then implanted them in the mouse sciatic nerve gaps (5 mm) (iPS group; n=10). The nerve conduit alone was implanted in the control group (n=10). After 4, 8 and 12 weeks, motor and sensory functional recovery in mice were significantly better in the iPS group. At 12 weeks, all the nerve conduits remained structurally stable without any collapse and histological analysis indicated axonal regeneration in the nerve conduits of both groups. However, the iPS group showed significantly more vigorous axonal regeneration. The bioabsorbable nerve conduits created by 3D-culture of iPS cell-derived neurospheres promoted regeneration of peripheral nerves and functional recovery in vivo. The combination of iPS cell technology and bioabsorbable nerve conduits shows potential as a future tool for the treatment of peripheral nerve defects.

Use of digital artery perforator flaps for repairing soft tissue defects after fasciectomy for Dupuytren's contractures in the ring and little fingers: A case report.

Fasciectomy is the standard treatment for Dupuytren's contracture, but, in many cases, skin defects may occur after fasciectomy. If the preoperative contracture is severe, the skin defect is large, which makes covering the defect difficult. We describe a case of severe skin defects after fasciectomy of Dupuytren's contractures in the ring and little fingers covered with multiple digital artery perforator (DAP) flaps . A 58-year-old man with extension restrictions of the ring and little fingers on his left hand was diagnosed with Dupuytren's contracture. The angles of insufficient extension were 70° and 40° for the metacarpophalangeal and proximal interphalangeal joints, respectively, of the little finger and 42° for the metacarpophalangeal joint of the ring finger. DAP flaps were used to cover the defect on the ring finger's metacarpophalangeal joint and little finger's proximal interphalangeal joint, whereas an ulnar palmar DAP flap was used on the defect on the little finger's metacarpophalangeal joint. The flaps survived without any complications, and, at 6 months postoperatively, satisfactory results were obtained. The extension angles were 0° for the metacarpophalangeal and proximal interphalangeal joints of the little finger and -5° for the ring finger's metacarpophalangeal joint. Such flaps can be designed to fit the width of the skin defect and can be applied to a large skin defect by combining the perforator flaps. Thus, the use of DAP flaps after fasciectomy to cover defects is considered helpful, even in cases of Dupuytren's contracture with severe extension restriction.

Ulnar Artery Perforator Adiposal Flap for Paraffinoma Treatment in a Patient With Leprosy: A Case Report.

Leprosy is a chronic infection in humans that mainly affects the peripheral nerves and skin. Paraffin filling has been previously used for muscle atrophy treatment. However, the formation of paraffin granulomas (paraffinomas) can occur over the long term. We encountered a patient with leprosy who had hypothenar muscle atrophy caused by ulnar neuropathy. The patient was treated with paraffin injection at the hypothenar site for cosmetic appearance 60 years ago. Consequently, the paraffin formed a paraffinoma and a recurrent infected skin ulcer. Thus, paraffinoma removal and transfer of ulnar artery perforator adiposal flap (140 × 20 mm) were performed. The ulnar artery perforator adiposal flap was used for infection control and filling the dead space after paraffin removal. The skin healed without complications. Ultrasound confirmed residual adipose tissue and blood flow at the last follow-up.

Association between Age and Trunk Muscle Area and Density in Patients with Spinal Metastases.

STUDY DESIGN: A retrospective study. PURPOSE: This study aimed to evaluate the relationship between age and trunk muscle composition and between trunk muscle composition and overall survival in patients with spinal metastasis. OVERVIEW OF LITERATURE: A low skeletal muscle mass is associated with a poor overall survival in patients with cancer. However, no previous studies have evaluated the relative effects of age and disease on muscle mass and muscle quality in patients with advanced cancer. METHODS: This study included 539 patients diagnosed with spinal metastasis from February 2009 to July 2018. The patients were categorized into four groups based on age: <59, 60-69, 70-79, and ≥80 years. Differences in trunk muscle composition among age groups and among groups were classified on the basis of survival (< or >3 months after spinal metastasis diagnosis) were evaluated. RESULTS: In total, 515 patients (273 men, 242 women; mean age, 67.8 years) with complete medical records were included in the analysis. No significant differences were observed in the area of the psoas and paravertebral muscles among age groups in either sex. A significant trend toward a low muscle density with the increase in age was found for both sexes. Patients who survived less than 3 months had significantly smaller trunk muscle area than those who survived for more than 3 months in both sexes. CONCLUSIONS: The results suggest that the reduction in muscle density is associated with advanced age, whereas a decreased muscle area is associated with pathology. Additionally, a small trunk muscle area was associated with a short overall survival. Further studies are needed to elucidate the underlying mechanisms of age- versus cancer-related changes in the muscle area and their influence on overall survival.

Bipedicled digital artery perforator volar adiposal turned-over flap for reconstruction of transverse fingertip amputation.

Different approaches to fingertip reconstructions are reported for cases in which microsurgical replantation is impossible. This report presents two cases of bipedicled digital artery perforator adiposal flaps for fingertip reconstruction after traumatic amputations. Adiposal flaps, including the radial and ulnar digital artery perforator vessels proximal to the distal interphalangeal joint, were elevated and turned to cover the fingertip defect. After donor-site skin closure, split-thickness skin was grafted onto the fingertip digital artery perforator adiposal flap. The technique is quick and easy to perform under loupe magnification and achieves good results in terms of healing, hand function, appearance, and patient satisfaction.

Thoracic Outlet Syndrome with Subclavian Artery Thrombosis Caused by Synostosis of the First and Second Ribs: A Case Report.

CASE: A 43-year-old woman presented with pain, paresthesia, and coldness of the right upper extremity suggestive of the diagnosis of thoracic outlet syndrome. Three-dimensional computed tomography angiography revealed that the right subclavian artery was constricted because it traveled over an abnormal first rib. After anticoagulation and antithrombotic therapy, the patient underwent resection of the abnormal first rib. Postoperative angiography documented improvement over time of the poststenotic dilatation and recanalization of the subclavian artery capable of delivering almost normal distal flow. CONCLUSION: Arterial reconstruction is not always necessary for the treatment of arterial thoracic outlet syndrome associated with poststenotic dilatation of the subclavian artery.