Genital gender-affirming surgery for transgender women.

Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.

Functional Outcomes of Nerve Allografts Seeded with Undifferentiated and Differentiated Mesenchymal Stem Cells in a Rat Sciatic Nerve Defect Model.

BACKGROUND: Mesenchymal stem cells have the potential to produce neurotrophic growth factors and establish a supportive microenvironment for neural regeneration. The purpose of this study was to determine the effect of undifferentiated and differentiated mesenchymal stem cells dynamically seeded onto decellularized nerve allografts on functional outcomes when used in peripheral nerve repair. METHODS: In 80 Lewis rats, a 10-mm sciatic nerve defect was reconstructed with (1) autograft, (2) decellularized allograft, (3) decellularized allograft seeded with undifferentiated mesenchymal stem cells, or (4) decellularized allograft seeded with mesenchymal stem cells differentiated into Schwann cell-like cells. Nerve regeneration was evaluated over time by cross-sectional tibial muscle ultrasound measurements, and at 12 and 16 weeks by isometric tetanic force measurements, compound muscle action potentials, muscle mass, histology, and immunofluorescence analyses. RESULTS: At 12 weeks, undifferentiated mesenchymal stem cells significantly improved isometric tetanic force measurement and compound muscle action potential outcomes compared to decellularized allograft alone, whereas differentiated mesenchymal stem cells significantly improved compound muscle action potential outcomes. The autografts outperformed both stem cell groups histologically at 12 weeks. At 16 weeks, functional outcomes normalized between groups. At both time points, the effect of undifferentiated versus differentiated mesenchymal stem cells was not significantly different. CONCLUSIONS: Undifferentiated and differentiated mesenchymal stem cells significantly improved functional outcomes of decellularized allografts at 12 weeks and were similar to autograft results in the majority of measurements. At 16 weeks, outcomes normalized as expected. Although differences between both cell types were not statistically significant, undifferentiated mesenchymal stem cells improved functional outcomes of decellularized nerve allografts to a greater extent and had practical benefits for clinical translation by limiting preparation time and costs.

The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty.

BACKGROUND: Penile inversion vaginoplasty is a commonly performed genital gender-affirming procedure in transgender women. The creation of an adequate functional neovaginal depth in cases of too little usable penile skin is a challenge. The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an easy adjunctive technique and may serve as a tool in the surgical armamentarium of the gender surgeon. AIM: To describe the use, dissection, design subtypes, and surgical outcomes of the BPES-flap in vaginoplasty. METHODS: Perioperative considerations and different flap design subtypes were described to illustrate the possible uses of the BPES-flap in vaginoplasty. A retrospective chart study was performed on the use of this flap in 3 centers (blinded for review purposes). OUTCOMES: The main outcome measures are description of surgical technique, flap design possibilities, and postoperative complications. RESULTS: A total of 42 transgender women were included (median age: 28 years (range 18-66), mean body mass index: 24.5 ± 3.5). The mean penile length and width preoperatively were 9 ± 3.1 and 2.9 ± 0.2 cm, respectively. With a mean follow up of 13 ± 10 months, total flap necrosis occurred in one case (2.4%). Partial flap necrosis occurred also in one. Neovaginal reconstruction was successful in all patients with a mean vaginal depth of 13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial prolapse of the neovaginal top occurred in 3 patients (7%). CLINICAL IMPLICATIONS: The BPES-flap is a useful addition to the arsenal of surgeons performing feminizing genital reconstructive surgery. STRENGTHS & LIMITATIONS: Strenghts comprise (1) the description of the surgical technique with clear images, (2) completeness of data, and (3) that data are from a multicenter study. A weakness is the retrospective nature with limited follow-up time. CONCLUSION: The BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial perineal arteries. It may be used for neovaginal depth creation during vaginoplasty and may be quicker to perform than full-thickness skin grafting. Nijhuis THJ, Özer M, van der Sluis WB, et al. The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty. J Sex Med 2020;17:1033-1040.

Gene expression and growth factor analysis in early nerve regeneration following segmental nerve defect reconstruction with a mesenchymal stromal cell-enhanced decellularized nerve allograft.

The purpose of this study was to evaluate the molecular mechanisms underlying nerve repair by a decellularized nerve allograft seeded with adipose-derived mesenchymal stromal cells (MSCs) and compare it to the unseeded allograft and autograft nerve. METHODS: Undifferentiated MSCs were seeded onto decellularized nerve allografts and used to reconstruct a 10 mm gap in a rat sciatic nerve model. Gene expression profiles of genes essential for nerve regeneration and immunohistochemical staining (IHC) for PGP9.5, NGF, RECA-1, and S100 were obtained 2 weeks postoperatively. RESULTS: Semi-quantitative RT-PCR analysis showed that the angiogenic molecule VEGFA was significantly increased in seeded allografts, and transcription factor SOX2 was downregulated in seeded allografts. Seeded grafts showed a significant increase in immunohistochemical markers NGF and RECA-1, when compared with unseeded allografts. CONCLUSIONS: MSCs contributed to the secretion of trophic factors. A beneficial effect of the MSCs on angiogenesis was found when compared with the unseeded nerve allograft, but implanted MSCs did not show evidence of differentiation into Schwann cell-like cells.

An Analysis of Aesthetic Refinements in 120 Secondary Cleft Rhinoplasties.

BACKGROUND: Secondary cleft nose rhinoplasty remains a challenging procedure. Cartilage memory and scar contraction are problematic factors. The need for more detailed procedures for secondary reconstruction in this patient population has arisen. Contemporary refinements demonstrate a highly structured approach. We conducted a retrospective study evaluating the aesthetic results of cleft patients who underwent secondary rhinoplasty. METHODS: In a retrospective study, a photometric analysis of cleft patients operated in the period 2003-2011 was conducted. Reconstructive methods were documented. Pre- and postoperative photographs of cleft rhinoplasty patients were evaluated using a standardized protocol. Nostril width ratio, columellar angle, tip projection ratio, and nasolabial angle served as objective instruments. The Unilateral Cleft Lip Surgical Outcomes Evaluation score was chosen for external photometric rating and rated blindly by 2 external individual plastic surgeons as independent nonbiased reviewers. The interrater and intrarater reliabilities were calculated using the Cohen kappa coefficient (κ). RESULTS: A total of 120 secondary rhinoplasties in 85 uni- and bilateral cleft patients could be included. Mean follow-up was 20 months. A total of 60 (71%) patients needed additional bone grafting (chin/pelvis), and 23 (27%) patients a LeFort I osteotomy. In one third of the secondary rhinoplasties, a medial and/or lateral osteotomy was performed (34%). In one fourth (24%), an external septoplasty was considered necessary. In 55% (47 patients) of the cases, a columellar strut was used. Excluding bone grafts, a total of 173 other grafts (mean of 2 grafts/patient) were applied. Postoperative measurements for nostril width ratio and columellar angle were statistically significant. A structured approach with contemporary refinements is described in detail. Intra- and interrater reliabilities for photometric assessment according to the Unilateral Cleft Lip Surgical Outcomes Evaluation score are shown. CONCLUSIONS: A structured approach for secondary cleft rhinoplasty yields satisfying, reproducible, and stable results.

Long-term scar quality after hydrosurgical versus conventional debridement of deep dermal burns (HyCon trial): study protocol for a randomized controlled trial.

BACKGROUND: Deep dermal burns require tangential excision of non-viable tissue and skin grafting to improve wound healing and burn-scar quality. Tangential excision is conventionally performed with a knife, but during the last decade hydrosurgery has become popular as a new tool for tangential excision. Hydrosurgery is generally thought to be a more precise and controlled manner of burn debridement leading to preservation of viable tissue and, therefore, better scar quality. Although scar quality is considered to be one of the most important outcomes in burn surgery today, no randomized controlled study has compared the effect of these two common treatment modalities with scar quality as a primary outcome. The aim of this study is, therefore, to compare long-term scar quality after hydrosurgical versus conventional tangential excision in deep dermal burns. METHODS/DESIGN: A multicenter, randomized, intra-patient, controlled trial will be conducted in the Dutch burn centers of Rotterdam, Beverwijk, and Groningen. All patients with deep dermal burns that require excision and grafting are eligible. Exclusion criteria are: a burn wound < 50 cm2, total body surface area (TBSA) burned > 30%, full-thickness burns, chemical or electrical burns, infected wounds (clinical symptoms in combination with positive wound swabs), insufficient knowledge of the Dutch or English language, patients that are unlikely to comply with requirements of the study protocol and follow-up, and patients who are (temporarily) incompetent because of sedation and/or intubation. A total of 137 patients will be included. Comparable wound areas A and B will be appointed, randomized and either excised conventionally with a knife or with the hydrosurgery system. The primary outcome is scar quality measured by the observer score of the Patient and Observer Scar Assessment Scale (POSAS); a subjective scar-assessment instrument, consisting of two separate six-item scales (observer and patient) that are both scored on a 10-point rating scale. DISCUSSION: This study will contribute to the optimal surgical treatment of patients with deep dermal burn wounds. TRIAL REGISTRATION: Dutch Trial Register, NTR6232 . Registered on 23 January 2017.

Rotational Advancement in Cleft Nose Rhinoplasty - Buccal Mucosal Grafts Serve as a Powerful Tool.

OBJECTIVE: Our aim was to analyze our technique of a modified rotational advancement in conjunction with buccal mucosal grafts (BMGs) in a subgroup of severe cleft cases. DESIGN: A retrospective clinical and photographic evaluation was conducted. Columella angle (CA) and tip projection (TPR) served as instruments in a photometric analysis. SETTING: Academic university hospital and specialized craniofacial cleft center. PATIENTS: At the time of the secondary rhinoplasty, 61 cleft patients were included, all 17 years or older. INTERVENTIONS: Rotational advancement with usage of BMGs was performed in selected cases by a single surgeon. MAIN OUTCOME MEASURES: Nasal symmetry and aesthetic appearance. RESULTS: From 2003 to 2011, 29 unilateral severe cleft cases (group I) underwent a modified alar rotational advancement with BMGs. Group II, with 32 cases, represented patients without BMGs. Technique and management of BMGs were described in detail. The complication rate of donor and recipient site presented as very low. The CA was improved significantly in both groups. Also, TPR improved (not significantly) in group I. Using our technique, we considerably enhanced the aesthetic results and symmetry in secondary cleft rhinoplast. CONCLUSIONS: Rotating the vestibular skin makes it possible to eliminate the traction of this skin on the repositioned alar cartilage, therefore achieving a more pleasing and stable nasal symmetry in secondary cleft rhinoplasty. Versatile BMGs close this gap, thus making them a powerful tool in the arsenal of the reconstructive cleft surgeon.

Ultrasound assessment of the sural nerve in patients with neuropathic pain after ankle surgery.

INTRODUCTION: The sural nerve may be damaged after ankle injury. The aim of our study was to determine the diagnostic utility of high-resolution sonography in patients with ankle fractures treated by open reduction and internal fixation in whom there was a clinical suspicion of sural neuropathy. METHODS: We examined the ultrasound (US) characteristics of patients with and without postsurgical sural neuropathic pain and healthy volunteers. Cross-sectional area (CSA), echogenicity, and vascularization of the sural nerves were recorded. RESULTS: Fourteen participants and all sural nerves were identified. CSA (P < 0.001) and vascularization (P = 0.002) were increased in symptomatic patients when compared with asymptomatic patients and healthy volunteers. There were no significant differences in nerve echogenicity (P = 0.983). DISCUSSION: US may be a valuable tool for evaluating clinically suspected sural nerve damage after ankle stabilization surgery. Sural nerve abnormalities are seen in patients with postsurgical neuropathic pain. Muscle Nerve 57: 407-413, 2018.

High Prevalence of Chronic Pain With Neuropathic Characteristics After Open Reduction and Internal Fixation of Ankle Fractures.

BACKGROUND: Unstable ankle fractures require treatment with open reduction and internal fixation (ORIF). Long-term functional outcome is satisfying in most patients; however, a number of patients have persistent complaints. Superficial nerve complications following ankle surgery may be the cause of chronic pain and disability. METHODS: In this observational retrospective survey, a cohort of 527 women and men, who underwent ORIF in the period from January 2007 to January 2014, were invited to an online questionnaire. Pain symptoms were assessed using the McGill Pain Questionnaire (MPQ) and the Douleur Neuropathic en 4 Questions (DN4) Questionnaire. Descriptive statistics were used to present patient characteristics; a logistic regression model was used to analyze prognostic factors of neuropathic pain. A total of 271 patients completed the questionnaire. Mean follow-up period was 5.8 years (±1.9). RESULTS: Persistent neuropathic pain symptoms were present in 61 of all patients, and 51 of these patients reported an impaired quality of life caused by their symptoms. In univariate analysis, the following parameters were associated with neuropathic pain: age, hypertension, a thyroid disorder, lower back pain, fracture dislocations, and late complications such as nonunion, posttraumatic arthritis, or osteochondral injury. In multivariate analysis, an age between 40 and 60 years was found to be a significant predictor of neuropathic pain. Hypertension, dislocation, and late complications were significant predictors of persistent pain without neuropathic characteristics. CONCLUSION: The present study demonstrated a prevalence of persistent neuropathic pain symptoms after ORIF for ankle fractures in 23% of the respondents, which caused an impaired health-related quality of life. We identified 4 significant predictors of chronic and neuropathic pain after ORIF. This knowledge may aid the treating surgeon to identify patients who are at increased risk of persistent postoperative neuropathic pain and may affect the treatment of pain in these patients. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Optimizing decellularization techniques to create a new nerve allograft: an in vitro study using rodent nerve segments.

OBJECTIVE Commercially available processed nerve allografts have been shown to be inferior to autografts in previous animal studies. The authors hypothesized that combining different processing and storage techniques will result in improved nerve ultrastructure preservation, lower immunogenicity, and minimized cellular debris. Different processing protocols were evaluated using chemical detergents, enzymes, and irradiation, with the addition the of enzyme elastase, were used. Additionally, the difference between cold and frozen storage was investigated. The goal of this study was to create an optimized nerve allograft. METHODS Fifty rat nerves were decellularized with modifications of previous protocols and the addition of elastase. Subsequently, the nerve segments were stored at either 4°C or -80°C. Both processed and fresh control nerves were analyzed with confocal microscopy using immunohistochemical staining on the basal lamina (laminin γ-1), Schwann cells (S100 protein), and immunogenicity using major histocompatibility complex-I (MHCI) staining. Morphology of the ultrastructure and amount of cellular debris were analyzed on cross-sections of the nerves stained with toluidine blue and H & E, and by using electron microscopy. RESULTS Nerve ultrastructure was preserved with all decellularization protocols. Storage at -80°C severely altered nerve ultrastructure after any decellularization method. Elastase was found to significantly reduce the immunogenicity and amount of Schwann cells, while maintaining good structural properties. CONCLUSIONS Reduced immunogenicity, diminished cellular debris, and the elimination of Schwann cells was observed when elastase was added to the nerve processing while maintaining ultrastructure. Storage at -80°C after the decellularization process heavily damaged the nerve ultrastructure as compared with cold storage. Further in vivo studies are needed to prove the nerve regenerative capacity of these optimized allografts.

Motor Nerve Recovery in a Rabbit Model: Description and Validation of a Noninvasive Ultrasound Technique.

PURPOSE: To develop and validate a noninvasive ultrasound technique for the longitudinal analysis of functional recovery after segmental peroneal nerve reconstruction in a rabbit model. METHODS: Twelve male New Zealand White rabbits underwent a 1-cm peroneal nerve autograft reconstruction. Ultrasound measurements were performed before surgery and at 1, 2, 4, 8, 12, and 16 weeks postoperatively. All rabbits were managed with manual restraint for the ultrasound procedure, avoiding the risks of anesthetics. At 12 and 16 weeks, we evaluated functional recovery using compound muscle action potential, isometric tetanic force measurements, wet muscle weight, and nerve histomorphometry. Data were compared with ultrasound measurements by calculating the Pearson correlation coefficient. We determined intra-rater and inter-rater reliability of the ultrasound measurements. RESULTS: Ultrasound demonstrated good correlation with isometric tetanic force measurements and wet muscle weight, good correlation with nerve histomorphometry, and moderate correlation with compound muscle action potential. Both intra-rater and inter-rater reliability of the ultrasound technique was excellent. CONCLUSIONS: Ultrasound analysis of the tibialis anterior muscle provided a reliable method for analysis of functional recovery in a rabbit peroneal nerve reconstruction model. The noninvasive nature allowed for longitudinal follow-up within the same animal and measurement of early recovery without the use of anesthesia. CLINICAL RELEVANCE: Application of this noninvasive technique can reduce the variability and sample size necessary in peripheral nerve reconstruction studies and may provide an ideal tool for comparative studies in larger animal models.

Noninvasive Ultrasound of the Tibial Muscle for Longitudinal Analysis of Nerve Regeneration in Rats.

BACKGROUND: Today's criterion standards for measuring functional recovery after nerve trauma in experimental studies are the muscle mass ratio and the isometric tetanic force; both tests are invasive and require a sacrificial procedure. The authors propose ultrasound as a noninvasive method to determine muscle atrophy, and evaluate its validity and reliability by comparing it to muscle mass ratio, isometric tetanic force, and histology. METHODS: Fifty rats sustained a 10-mm autograft sciatic nerve reconstruction. With a 2-week interval, five animals were tested with a total follow-up of 20 weeks. The functional recovery of the hind-limb muscles was measured with ultrasound, muscle mass ratio, and isometric tetanic force. In addition, neuromuscular junctions were analyzed histologically. The different evaluation techniques were compared and the reliability of the ultrasound was determined. RESULTS: Four weeks after denervation, extensive muscle atrophy resulted in a decrease of muscle mass up to 30 percent. Ultrasound showed good correlations with muscle mass ratio for both tibial (r = 0.85) and gastrocnemius muscles (r = 0.89). Both intrarater reliability (r = 0.97) and interrater reliability (r = 0.88) of the ultrasound were high. The correlation with force was lower (0.62) but still statistically significant. CONCLUSIONS: Ultrasound measurement of muscle atrophy was highly correlated with the criterion standard muscle mass ratio and was also significantly correlated with isometric tetanic force. Histologic evaluation confirmed the regeneration pattern observed with ultrasound. The authors propose that ultrasound can be used as a valid alternative to muscle mass ratio to study muscle atrophy after nerve injury in a less-invasive and more animal-friendly manner.

Long-term follow-up of peptidergic and nonpeptidergic reinnervation of the epidermis following sciatic nerve reconstruction in rats.

OBJECT: Peripheral nerve injuries are a commonly encountered clinical problem and often result in long-term functional deficits. The current gold standard for transected nerves is an end-to-end reconstruction, which results in the intermittent appearance of neuropathic pain. METHODS: To improve our understanding of the relation between this type of reconstruction and neuropathic pain, the authors transected and immediately end-to-end reconstructed the sciatic nerve in rats. The effect of this procedure on neuropathic pain, as measured by thermal and mechanical hypersensitivity at 4 different time points (5, 10, 20, and 30 weeks), was related to the density of peptidergic and nonpeptidergic fiber innervation in the glabrous skin of rats' hind paws. RESULTS: Thermal hypersensitivity occurring 20 weeks after reconstruction was accompanied by a significant increase in peptidergic epidermal fibers. However, the lesion-induced reduction in the density of nonpeptidergic epidermal fibers remained decreased at all experimental time points. Moreover, temporal collateral sprouting by undamaged saphenous nerve was visualized using the recently revised Evans blue extravasation technique. Strikingly, as the sciatic nerve repopulated rats' hind paw, the saphenous nerve withdrew to its original territory. CONCLUSIONS: The authors conclude that the transient thermal hypersensitivity is related to increased density of epidermal peptidergic fibers, which mainly originate from regenerating fibers. Furthermore, a changed composition in the peptidergic and nonpeptidergic epidermal fibers is demonstrated following end-to-end reconstruction of the sciatic nerve.

Prognostic factors for outcome after median, ulnar, and combined median-ulnar nerve injuries: a prospective study.

BACKGROUND: A major problem in the surgical treatment of peripheral nerve injuries of the upper extremities is the unpredictable final outcome. More insight and understanding of the prognostic factors is necessary to improve functional outcome after repair of the peripheral nerves. The objective of this study was to identify prognostic factors for the functional recovery of peripheral nerve injury of the forearm and their independent contribution in the outcome in the first year after reconstruction. METHODS: A multicentered prospective study in the Netherlands resulted in the inclusion of 61 patients with a median, ulnar, or combined median-ulnar nerve injury. The age, level of injury, type of nerve injury, number of damaged structures, number of damaged arteries, education, smoking, and posttraumatic stress were analyzed as prognostic factors for functional outcome after repair of the peripheral nerves. The outcome parameters were sensory recovery (Semmes-Weinstein monofilament test) and motor recovery (Medical Research Council (MRC) score, power grip, and pinch grip) and the ability to perform daily activities. RESULTS: Gender, age, level of education, number of injured arteries and structures, damaged nerve, location of the injury, type of the nerve injury, and posttraumatic stress at 1 and 3 months after repair of the peripheral nerve injury were found to be predictors of functional recovery. CONCLUSIONS: Our prospective analysis of prognostic factors shows several factors to be predictive for the functional recovery after peripheral nerve injuries of the median and/or ulnar nerve of the forearm. Sensibility of the hand, power grip, and DASH score (DASH, Disabilities of Arm, Shoulder and Hand) have proven to be the three best prognostic factors in this study. Of these prognostic factors, only posttraumatic stress can be influenced to optimize functional outcome.

The effect of stem cells in bridging peripheral nerve defects: a meta-analysis.

UNLABELLED: OBJECT.: For decades the gold standard for reconstructing a large peripheral nerve defect has been, and remains, the nerve autograft. Alternatives to the nerve autograft include biological conduits and vessels. Adding stem cells in the lumen of a nerve conduit has been the subject of multiple studies. The purpose of the present meta-analysis was to summarize animal experimental studies on the effect of stem cells as a luminal additive when reconstructing a peripheral nerve defect with a nerve graft. METHODS: A literature search of the MEDLINE and Embase databases was performed from inception to April 2012, searching for animal experiments on peripheral nerve reconstruction models in which a nerve conduit was used with and without the support of 3 different types of stem cells. Stem cells were analyzed according to their origin: bone marrow, adipose tissue, and other origins. Included studies had consistent outcome measurements: walking track analysis, muscle mass ratio, and electrophysiology. RESULTS: Forty-four studies were included in the final analysis. Forest plots of the 3 outcome measurements (walking track analysis, muscle mass ratio, and electrophysiology) showed positive effects of stem cells on the regeneration of peripheral nerves at different time points. Almost all comparisons showed significant differences for all 3 stem cells groups compared with a control group in which stem cells were not used. CONCLUSIONS: The present report systematically analyzed the different studies that used stem cells as a luminal additive when bridging a large peripheral nerve defect. All 3 different stem cell groups showed a beneficial effect when used in the reconstruction compared with control groups in which stem cells were not used.

An experimental study to determine and correlate choline acetyltransferase assay with functional muscle testing after nerve injury.

OBJECT Choline acetyltransferase (ChAT) is an enzyme synthesized within the body of a motor neuron whose role is to form the neurotransmitter acetylcholine. Quantification of ChAT levels in motor or mixed nerves has been proposed to provide information regarding the viability of a proximal nerve stump for motor neurotization following brachial plexus injury. To do so requires information regarding normal ChAT levels and those in injured nerves, as well as the correlation of ChAT level determined at surgery with eventual motor recovery. The purpose of this study was to determine ChAT activity in the normal and injured sciatic/peroneal nerve in a rat model, evaluate the correlation between ChAT and motor recovery, find the relationship between ChAT activity and isometric muscle force, and elucidate the parallel between ChAT activity and acetylcholinesterase (AChE) activity. METHODS Sixty animals were divided into 3 groups. The sciatic nerves in Group 1 were transected without repair. Nerves in Group 2 were transected and repaired. Nerves in Group 3 sustained a crush injury followed by transection and reconstruction. All animals were allowed 12 weeks of recovery followed by evaluation of ChAT levels in the peroneal nerve, correlated with measures of maximal isometric tibialis anterior muscle force and muscle weight (the operated side normalized to the control side). Karnovsky AChE staining of peroneal nerve segments was also compared with radiochemical assay of ChAT activity in the same nerve. RESULTS A significant difference in the tibialis anterior isometric tetanic force and the tibialis anterior muscle weight index (TAMI) was noted between Group 1 and Groups 2 and 3 (p < 0.0001); no significant difference was found comparing Group 2 with Group 3. The correlation between the force measurement and the TAMI was 0.382. Both AChE measurement and ChAT activity demonstrated significantly fewer fibers in the operated nerve compared with the contralateral nerve. Intergroup variability could also be illustrated using these tests. The correlation coefficient between the isometric tetanic force measurement and the ChAT analysis in Groups 1 and 2 was 0.468. The correlation for the AChE staining and the isometric tetanic force measurement was 0.111. The correlation between the TAMI and the ChAT levels was 0.773. The correlation between the TAMI and the AChE-stained fibers was 0.640. Correlating AChE staining to the ChAT analysis produced a correlation of 0.712. CONCLUSIONS The great variability in all groups and weak correlations to the functional muscle assessments and the ChAT radiochemical assay made this technique an unreliable method of determining motor nerve viability.

Early posttraumatic psychological stress following peripheral nerve injury: a prospective study.

BACKGROUND: Psychological symptoms frequently accompany severe injuries of the upper extremities and are described to influence functional outcome. As yet, little knowledge is available about the occurrence of posttraumatic psychological stress and the predictive characteristics of peripheral nerve injuries of the upper extremity for such psychological symptoms. In this prospective study, the incidence of different aspects of early posttraumatic stress in patients with peripheral nerve injury of the forearm is studied as well as the risk factors for the occurrence of early psychological stress. METHODS: In a prospective study design, patients with a median, ulnar or combined median-ulnar nerve injury were monitored for posttraumatic psychological stress symptoms with the Impact of Event Scale (IES) questionnaire up to 3 months postoperatively. RESULTS: Psychological stress within the first month after surgery occurred in 91.8% of the population (IES mean=22.0, standard deviation (SD)=17.3). Three months postoperatively, 83.3% (IES mean=13.3, SD=14.1) experienced psychological stress. One month postoperatively 24.6% and 3 months postoperatively 13.3% of the patients had IES scores indicating for the need for psychological treatment. Female gender, adult age and combined nerve injuries were related to the occurrence of psychological stress symptoms 1 month postoperatively. CONCLUSIONS: In the majority of these patients, peripheral nerve injury of the forearm is accompanied by early posttraumatic psychological stress, especially in female adults who suffered from combined nerve injuries.

A new approach to assess the gastrocnemius muscle volume in rodents using ultrasound; comparison with the gastrocnemius muscle index.

INTRODUCTION: The purpose of this study was to determine the reliability and validity of a new non-invasive ultrasound technique to measure gastrocnemius muscle atrophy after nerve denervation in an animal model. METHODS: In sixteen rodents an eight mm sciatic nerve gap was created. In the following 8 weeks, each week, two rodents were euthanized and the gastrocnemius muscle was examined using two different ultrasound systems and two investigators. The standardized ultrasound measurement protocol consisted of identifying pre-defined anatomical landmarks: 1) the fibula, 2) the fibular nerve, and 3) the junction between the most distal point of the semitendinosus muscle and gastrocnemius muscle. Consequently, we measured the muscle thickness as the length of the line between the fibula and the junction between the two muscles, perpendicular to the fibular nerve. After the ultrasound recording, the muscle mass was determined. RESULTS: A steep decline of muscle weight of 24% was observed after one week. In the following weeks, the weight further decreased and then remained stable from 6 weeks onwards, resulting in a maximal muscle weight decrease of 82%. The correlation coefficient was >0.96 between muscle diameter and weight using both ultrasound systems. The inter-rater reliability was excellent for both devices on the operated side (ICC of 0.99 for both ultrasound systems) and good for the non-operated site (ICC's: 0.84 & 0.89). The difference between the muscle mass ratio and the muscle thickness ratio was not more than 5% with two outliers of approximately 13%. DISCUSSION: We have developed an innovative, highly reliable technique for quantifying muscle atrophy after nerve injury. This technique allows serial measurements in the same animal over time. This is a significant advantage compared to the conventional technique for quantifying muscle atrophy, which requires sacrificing the animal.

Osteoradionecrosis of the jaws: a review of conservative and surgical treatment options.

Although surgery still is the most important treatment modality in the management of head and neck cancer, radiotherapy is increasingly being used. Consequently, the majority of head and neck cancer patients are at risk of developing osteoradionecrosis of the jaws, which is the most serious and important complication of radiotherapy. This review presents the etiology, pathophysiology, diagnosis, classification, and prevention of osteoradionecrosis. In addition, the body of evidence regarding conservative as well as surgical treatment of osteoradionecrosis is reviewed, and studies on complications, tumor recurrence and patient survival, dental rehabilitation, and functional and aesthetic outcome after surgical treatment for osteoradionecrosis are discussed.