[Anatomical cartography of the radial nerve at the elbow level for intraradial nerve transfers for finger extension reconstruction in spastic upper limb - A cadaveric study]. / Cartographie anatomique du nerf radial dans la région du coude pour son application aux transferts nerveux intraradiaux dans la chirurgie de la spasticité.

INTRODUCTION: Upper limb spasticity is a surgical challenge, both in diminishing agonists spasticity and reconstructing antagonist function. Brachioradialis (BR) is often involved in elbow flexors spasticity. Finger extension is often impaired in spastic patients. This study aims to demonstrate the feasibility of BR motor branch to posterior interosseous nerve (PIN) during BR selective neurectomies, and to describe fascicles topography inside the radial nerve to facilitate PIN dissection. MATERIAL AND METHOD: Ten upper limbs from 10 fresh frozen anatomical specimens were dissected. Motor branches to the BR, wrist extensors, supinator, PIN and radial sensory branch were identified. BR to PIN transfer was realized and its feasibility was studies (donor length, tensionless suture). RESULTS: BR to PIN transfer was achievable in 9 out of 10 cases. The position of the sensory branch of the radial nerve was inferior or medial in all cases. The position of the PIN was lateral in 90% of the cases. CONCLUSION: BR to PIN nerve transfer is achievable in most cases (90%). The lateral topography of the PIN and the inferomedial topography of the sensory branch in most cases allows for an easier intraoperative finding of the PIN when stimulation is not possible. LEVEL: IV, feasibility study.

[Phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery]. / Phallopoièse par lambeau antébrachial radial libre dans la chirurgie de réassignation sexuelle femme à homme.

AIMS: The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications. METHODS: In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery. RESULTS: The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant. CONCLUSION: Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals.

[Description of a vaginoplasty technique using a peritoneal flap harvested by coelioscopic approach for male-to-female gender affirmations (MtF)]. / Description d'une technique de vaginoplastie utilisant un lambeau péritonéal prélevé par voie cœlioscopie pour les affirmations de genre homme-à-femme (HtF).

AIM: The aim of this article is to provide a comprehensive description of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery, particularly in cases of insufficient depth after penile inversion vaginoplasty. RESULTS: Our short-term results reveal that the peritoneal flap vaginoplasty, adapted from the Davydov procedure, has shown significant potential for improving functional and aesthetic outcomes, including the creation of a self-lubricating neovagina. However, the complexity of the procedure requires advanced surgical expertise and appropriate postoperative care. Patient selection also plays an essential role as not all patients are ideal candidates for this procedure. CONCLUSION: Despite its promises, the widespread adoption of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery is hindered by several challenges, including the need for specialized training and potential postoperative complications. Thus, this technique should be considered as an alternative or complement to traditional methods, depending on individual patient factors. Further research and extensive clinical trials are needed to better understand its potential and limitations in order to enhance the arsenal of effective surgical options for MtF gender affirmation surgery.

[Transfer of the pronator quadratus to restore opposition of the thumb: An anatomic study and a clinical report]. / Étude anatomique sur le lambeau de carré pronateur pédiculé réinnervé pour réanimer l'opposition du pouce et application clinique.

OBJECTIVE: The purpose of this study is to explore the feasibility of reconstructing the APB with a pedicled PQ flap, and to report results in a child presenting with bilateral radial deficiency. METHODS: Twenty-one injected cadaver upper extremities were dissected. The muscle was pedicled distally on the transverse carpal artery, and reinnervated with the flexor digiti minimi (FDM) motor branch. The transfer was evaluated on 3 parameters: surgical feasibility, length of the distal pedicle and distance from the coaptation site to the muscle entry of recipient nerve. A bilateral PQ pedicled transfer was accomplished in a 17-month old child with bilateral radial deficiency. RESULTS: In the cadaver study, transfer of PQ to the APB was feasible and the distal end of the PQ transfer was reaching the radial side of the first metacarpophalangeal joint in all cases. The length of the distal pedicle on the transverse carpal artery was 38.5±0.20mm. The distance from coaptation of the FDM to the PQ muscle entry was 43.0±3.77mm. At 7 months, there was a cosmetic improvement of the thenar eminence, a bilateral M3 abduction of the thumb and a functional improvement from bilateral PQ pedicled transfer. CONCLUSIONS: Reconstruction of the APB may be achieved with a PQ pedicled transfer reinnervated, improving the function and the cosmetic aspect of the thenar eminence without sacrificing any function of the hand.

Management of complex forearm defects: A multidisciplinary approach.

Complex forearm defects with significant damage to, or loss of skin, tendon, muscle, bone and neurovascular structures represent a great challenge for surgeons. The management of such injuries, whether a result of trauma or tumor resection, is focused on preservation of the damaged limb and restoration of hand function. A multidisciplinary approach combining plastic and orthopedic surgical expertise in a coordinated team is proposed to address these challenging cases. The authors have laid emphasis on adequate debridement for wound bed preparation, bone stabilization and reconstruction for a stable bony framework, vascular repair for early revascularization, musculotendinous and nerve reconstruction as well as vascularized tissue coverage on a case-to-case basis to facilitate optimal functional recovery. They also maintain that besides expedient surgical treatment, early mobilization based on an individualized rehabilitation program as well as psychological and socio-professional supports are necessary means of achieving rapid and successful social integration.

Aesthetic functional reconstruction of the mutilated hand: Indications and selection of reconstructive techniques.

Advances in microsurgery together with improvements in reconstructive surgical techniques over recent decades have enlarged the scope of available techniques for mutilated hand reconstruction, shifting the reconstructive paradigm from restoring hand function to providing the best functional and aesthetic results with minimal donor-site morbidity. Successful reconstruction of a mutilated hand should no longer be measured only by the degree of improvement of hand function but also by a more aesthetic hand appearance as well as by improved psychological well-being. In this article, the authors present their concept of aesthetic functional reconstruction of the mutilated hand with a focus on the indications and selection of reconstructive techniques. They emphasize that in order to select the most appropriate technique, providing the best functional and aesthetic outcomes with minimal donor-site morbidity for each individual patient, it is imperative for the reconstructive hand surgeon to possess perfect mastery of all available surgical techniques, thorough understanding of functional and aesthetic requirements and accurate appreciation of multidimensional reconstruction of a given defect of the hand. They have concluded that in precisely indicated cases, successful replantation of an amputated hand or digits remains the best reconstructive procedure designed to obtain a more functional and more normal-appearing hand, whereas, toe-to-hand transplantation, in cases of failed or impossible digit replantation, provides better results than any other digit reconstruction techniques aimed at achieving functioning digits with good appearance. Although skin graft and various distant pedicled flaps and free flaps may be valid options for coverage of some soft tissue defects of the hand, reverse flow forearm flaps, especially those based on the secondary arteries of the forearm, are often the best-suited reconstructive options for like-with-like hand reconstruction. They can provide the best matching of color, texture, soft-tissue volume, donor-recipient tissue interface and fulfill all the aesthetic and functional reconstruction requirements of moderate-sized or even large soft tissue defects of the hand, with acceptable donor site morbidity.

Comparison between isotropic linear-elastic law and isotropic hyperelastic law in the finite element modeling of the brachial plexus.

Augmented reality could help the identification of nerve structures in brachial plexus surgery. The goal of this study was to determine which law of mechanical behavior was more adapted by comparing the results of Hooke's isotropic linear elastic law to those of Ogden's isotropic hyperelastic law, applied to a biomechanical model of the brachial plexus. A model of finite elements was created using the ABAQUS® from a 3D model of the brachial plexus acquired by segmentation and meshing of MRI images at 0°, 45° and 135° of shoulder abduction of a healthy subject. The offset between the reconstructed model and the deformed model was evaluated quantitatively by the Hausdorff distance and qualitatively by the identification of 3 anatomical landmarks. In every case the Hausdorff distance was shorter with Ogden's law compared to Hooke's law. On a qualitative aspect, the model deformed by Ogden's law followed the concavity of the reconstructed model whereas the model deformed by Hooke's law remained convex. In conclusion, the results of this study demonstrate that the behavior of Ogden's isotropic hyperelastic mechanical model was more adapted to the modeling of the deformations of the brachial plexus.

Analysis of the modifications of MRI signal of the brachial plexus of rats: Comparative study before and after freezing/thawing.

The aim of this study was to compare the MRI signal of the brachial plexus and surrounding muscles before and after freezing/thawing on a murine model. A first MRI going through the brachial plexuses of 5 healthy Wistar rats was performed immediately post-mortem. A second MRI was performed after freezing at -30°C and then thawing at 20°C for 24hours. All MRI images were segmented to make nerve and muscular structures appear and calculate the average intensity of the MRI signal using the program ImageJ. The average nerve and muscular MRI signals were compared before and after freezing/thawing and rated in grayscale units between 0 and 255. The average intensity of the MRI signal of nerve structures was 40.315 grayscale units before freezing and 31.943 after freezing/thawing. The average intensity of the MRI signal of muscular structures was 25.44 grayscale units before freezing and 35.710 after freezing/thawing. Our results have shown that the intensity of the MRI signal of the brachial plexus was higher before freezing/thawing. The intensity of the MRI signal of muscles was lower than the intensity of the brachial plexus before freezing/thawing and higher after freezing/thawing in muscles than in brachial plexus. The MRI could be used in clinical practice to monitor the reinnervation after frozen nerve allografts.