Traction-assisted Internal Negative Pressure Wound Therapy With Bridging Retention Sutures to Facilitate Staged Closure of High-risk Wounds Under Tension.

BACKGROUND/OBJECTIVE: Loss of domain often complicates attempts at delayed wound closure in regions of high tension. Wound temporization with traction-assisted internal negative pressure wound therapy (NPWT), using bridging retention sutures, can minimize the effects of edema and elastic recoil that contribute to progressive tissue retraction over time. The investigators evaluated the safety and efficacy of this technique for complex wound closure. MATERIALS AND METHODS: Between May 2015 and November 2015, 18 consecutive patients underwent staged reconstruction of complex and/or contaminated soft tissue defects utilizing either conventional NPWT or modified NPWT with instillation and continuous dermatotraction via bridging retention sutures. Instillation of antimicrobial solution was reserved for wounds containing infected/exposed hardware or prosthetic devices. Demographic data, wound characteristics, reconstructive outcomes, and complications were reviewed retrospectively. RESULTS: Eighteen wounds were treated with traction-assisted internal NPWT using the conventional (n = 11) or modified instillation (n = 7) technique. Defects involved the lower extremity (n = 14), trunk (n = 3), and proximal upper extremity (n = 1), with positive cultures identified in 12 wounds (67%). Therapy continued for 3 to 8 days (mean, 4.3 days), resulting in an average wound surface area reduction of 78% (149 cm² vs. 33 cm²) at definitive closure. Seventeen wounds (94%) were closed directly, whereas the remaining defect required coverage with a local muscle flap and skin graft. At final follow-up (mean, 12 months), 89% of wounds remained closed. In 2 patients with delayed, recurrent periprosthetic infection (mean, 7.5 weeks), serial debridement/hardware removal mandated free tissue transfer for composite defect reconstruction. CONCLUSION: Traction-assisted internal NPWT provides a safe and effective alternative to reduce wound burden and facilitate definitive closure in cases where delayed reconstruction of high-tension wounds is planned.

Use of indocyanine green fluorescent angiography in a hyperbaric patient with soft tissue radiation necrosis: a case report.

INTRODUCTION: Indocyanine green fluorescent angiography (ICFA), commonly used to assess vascularity in patients with non-healing lower extremity wounds, is emerging as a useful adjunct for hyperbaric oxygen (HBO2)therapy patients. We describe the use of ICFA to measure vascularity and help tailor an appropriate HBO2 regimen in a patient with breast soft tissue radiation necrosis (STRN). CASE REPORT: 67-year-old female with a history of right breast cancer treated two years previously with lumpectomy and radiation therapy (6200 cGy), developed open wounds in the right breast. A diagnosis of STRN was established; the patient completed 20 HBO2 treatments, followed by surgical closure of the right breast wounds. Intraoperative ICFA demonstrated a focal area of hypovascularity at the medial margin of the incision. Due to a concern of suboptimal vascularity, the patient returned for additional HBO2 treatments. ICFA was performed after eight postoperative HBO2 treatments, and showed improved vascularity in the previously identified area of concern. DISCUSSION: Studies of patients previously irradiated for head and neck cancer suggest that HBO2-induced vascularity is apparent after approximately eight HBO2 treatments and peaks around 20 treatments. The results from this case indicate that the doses of HBO2 needed for adequate neovascularization in patients with STRN may be variable. CONCLUSION: The use of ICFA may provide additional insight regarding HBO2-induced angiogenesis. Additional studies are required to establish the correct number of HBO2 treatments required for angiogenesis in previously irradiated patients with STRN, and to explore the role of ICFA in patients treated with HBO2.

Prevention of Painful Neuroma and Phantom Limb Pain After Transfemoral Amputations Through Concomitant Nerve Coaptation and Collagen Nerve Wrapping.

BACKGROUND: Postamputation pain is a debilitating condition that affects almost 60% of transfemoral amputees. Recent appreciation for the contribution of peripheral nerve derangement to the development of postamputation pain has resulted in focus on the role of nerve reconstruction in preventing pain after amputation. OBJECTIVE: To propose a method involving tibial and common peroneal nerve coaptation at the time of amputation, as a means to prevent residual limb pain and phantom sequelae resulting from neuroma formation. METHODS: Between May 2014 and May 2015, 17 patients underwent transfemoral amputation and nerve management through either (1) common peroneal nerve-to- tibial nerve coaptation and collagen nerve wrapping or (2) traction neurectomy alone. Visual analog scores (VAS) for pain, analgesic requirements, neuroma formation, phantom pain/sensations, and ambulatory status were compared between cohorts. RESULTS: Six patients underwent nerve coaptation/collagen nerve wrapping, whereas 11 underwent traction neurectomy. At 2 months, VAS scores were similar between cohorts (3 vs 3.82; P = .88); however, neuroma (0% vs 36.3%; P = .24) and phantom pain (0% and 54.5%; P = .03) were significantly lower after coaptation. After 6 months, VAS scores (0.75 vs 5.6; P = .02) as well as neuroma (0% vs 54.5%; P = .03) and phantom pain (0% vs 63.6%; P = .01) remained lower among patients who underwent coaptation. At follow-up, 67% of coaptation patients were ambulating with a prosthesis vs 9% of neurectomy patients (P = .01). CONCLUSION: Preemptive coaptation and collagen nerve wrapping is associated with lower VAS pain scores, phantom symptoms, and neuroma formation, with higher ambulation rates after 6 months when compared with traction neurectomy alone. ABBREVIATIONS: CPN, common peroneal nervePAP, Postamputation painPLP, phantom limb painPS, phantom sensationsRLP, residual limb painTN, tibial nerve.

Cadaveric nerve allotransplantation in the treatment of persistent thoracic neuralgia.

When relief from neuralgia cannot be achieved with traditional methods, neurectomy may be considered to abate the stimulus, and primary opposition of the terminal nerve ending is recommended to prevent neuroma. Nerve repair with autograft is limited by autologous nerves available for large nerve defects. Cadaveric allografts provide an unlimited graft source without donor-site morbidities, but are rapidly rejected unless appropriate immunosuppression is achieved. An optimal treatment method for nerve allograft transplantation would minimize rejection while simultaneously permitting nerve regeneration. This report details a novel experience of nerve allograft transplantation using cadaveric nerve grafts to desensitize persistent postoperative thoracic neuralgia.

Predictive Value of Nutritional Markers for Wound Healing Complications in Bariatric Patients Undergoing Panniculectomy.

BACKGROUND: Hypoproteinemia and nutritional deficiencies are common after bariatric surgery, and although massive weight loss (MWL) patients experience increased wound complication rates, the association has not been causatively determined. OBJECTIVES: This study investigated preoperative nutritional parameters and wound complications in MWL patients (postbariatric and diet-controlled) undergoing panniculectomy at 2 academic institutions. METHODS: One hundred sixty-one consecutive patients undergoing elective panniculectomy after bariatric surgery or diet-controlled weight loss were identified. Patient demographics and nutritional indices (serum protein, albumin, and micronutrient levels) were analyzed. Complications including wound separation, infection, and operative debridements were compared. Post hoc comparisons tested for correlation between complications and nutritional markers. RESULTS: Postbariatric patients lost an average of 151 lb and presented at an average of 32 months after gastric bypass. Diet-controlled weight loss patients lost an average of 124 lb. Despite MWL, albumin levels were higher in the bariatric group (3.8 vs 3.4 g/dL, P < 0.05). Conversely, bariatric patients experienced increased wound complications (27% vs 14%; P < 0.05). Factors which were found to correlate to increased risk of wound dehiscence and infection were elevated body mass index at time of panniculectomy and amount of tissue removed. Multivariate analysis did not show serum albumin or percent weight loss to independently predict complications. CONCLUSIONS: Bariatric patients presenting for elective operations are at risk for protein and micronutrient deficiency. Despite aggressive replacement and normalization of nutritional markers, bariatric patients experience increased wound complications when compared to nonbariatric patients and traditional measures of nutritional evaluation for surgery may be insufficient in bariatric patients.

Management of advanced plexiform neurofibromatosis of the foot presenting with skeletal deformation and intractable pain: an indication for proximal amputation.

Plexiform neurofibromas of the foot are rare and often present with significant pain, deformity, and functional impairment secondary to their locally invasive behavior. While treatment has traditionally focused on attempts at radical resection, a lack of consensus among surgeons has hindered the establishment of a well-defined algorithm to guide the management of these highly co-morbid peripheral nerve sheath tumors. We present the case of an advanced plexiform neurofibroma of the right foot in a 24-year-old male with neurofibromatosis type 1. The patient presented following accelerated tumor growth with extensive osseous erosion, intractable pain, and progressive ankle instability that limited his capacity to ambulate and wear shoes. A modified transtibial amputation with a vascularized fibular bone graft (Ertl procedure) was performed without complication. Following graduated rehabilitation, postoperatively, the patient regained functional independence and was able to ambulate without pain in a customized prosthesis after 3 months. Plexiform neurofibromas of the foot present a complex challenge for foot and ankle surgeons. On the basis of our experience and previously reported cases, we advocate for amputation over aggressive attempts at advanced limb salvage for patients with extensive skeletal destruction, joint instability, and/or intractable pain caused by tumor mass effect.

Nerve entrapment: update.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Understand the pathophysiology of chronic nerve compression. 2. Describe the evaluation of a patient presenting with compression neuropathy. 3. Discuss the current controversies in the management of compression neuropathies. 4. Describe the treatment of common compression neuropathies, including carpal and cubital tunnel syndromes. SUMMARY: Nerve entrapment syndromes are common in the general population, and are managed by a wide variety of medical and surgical specialists. A thorough understanding of the pathophysiology of nerve compression and appropriate clinical workup are critical in the overall management of these conditions. There remain several topics of controversy regarding the surgical management of nerve entrapment syndromes, including multiple points of nerve compression, carpal tunnel release under local anesthesia, open versus endoscopic decompression surgery, the "best" operation for primary cubital tunnel surgery, and revision decompression surgery. This article attempts to provide a concise summary of the advances in the basic and clinical science of peripheral nerve entrapment.

Recurrent digital infections and osteomyelitis in monozygotic twins with congenital analgesia and compulsive onychophagia.

Congenital insensitivity to pain is a rare sensory neuropathy that manifests with multiple and recurrent injuries secondary to a lack of negative pain stimuli. When present with compulsive onychophagia, prompt recognition and behavioral management to prevent chronic digital infection or amputation is imperative. We present the case of two 7 year-old monozygotic twins that presented with congenital insensitivity to pain and compulsive onychophagia without directed parental counseling or behavioral modification strategies. The presenting child was noted to have an acute digital felon and osteomyelitis of several distal phalanges, and the sister had a similar history with distal phalangeal amputations. The occurrence of these overlapping disorders in monozygotic twins has not been previously reported, however, patient and parental education with behavioral modifications of injurious and compulsive behavior is the cornerstone of management. In addition, we have provided a review of the diagnosis for clinical differentiation.

Surgical decompression of the great auricular nerve: a therapeutic option for neurapraxia following rhytidectomy.

BACKGROUND: Great auricular nerve injuries are the most frequent nerve injuries following rhytidectomy, occurring at a rate of 6 percent. Short-scar techniques may decrease visualization and increase the risk of injury/compression of the great auricular nerve. Recent reviews have identified that great auricular nerve injury can contribute to long-term paresthesias and allodynia in a majority of patients. Identification of this injury, with subsequent exploration, wide release, and decompression, should be performed. METHODS: Four patients with injury of the great auricular nerve were referred for persistent allodynia as a complication of short-scar rhytidectomy. Following confirmation of a Tinel sign over the great auricular nerve, each patient underwent subsequent exploration and neurolysis. RESULTS: Diagnosis of compression and suture impingement was confirmed at exploration, and extensive decompression was performed with care taken to protect the nerve from postoperative scar formation. All patients noted postoperative improvement in symptoms, with nearly complete resolution at 6 months. CONCLUSIONS: Minimally invasive techniques may impart increased risk of nerve injury in exchange for reduced scar length. In instances of great auricular nerve injury, progressive metabolic changes and increased vascular permeability allow for inflammatory cellular influx and fibrin deposition, compounding nerve dysfunction and symptomatic complaints. Noninvasive modalities may not alleviate complaints of pain and hyperesthesia, particularly in the event of suture compression. Persistent injuries can affect quality of life, with intrusive thoughts about symptoms, or an inability to perform grooming activities. Exploration and decompression of the great auricular nerve may offer a long-term solution for the patient with postrhytidectomy allodynia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Transfer of the extensor digiti minimi and extensor carpi ulnaris branches of the posterior interosseous nerve to restore intrinsic hand function: case report and anatomic study.

PURPOSE: To present a technique for restoration of ulnar intrinsic function using a nerve transfer of the extensor carpi ulnaris (ECU) and extensor digiti minimi (EDM) nerve branches of the posterior interosseous nerve (PIN) to the deep branch of the ulnar nerve in the forearm when the anterior interosseous nerve is unavailable. METHODS: We dissected 6 cadaveric upper extremities to identify the location of the EDM and ECU branches of the PIN and their distance to the ulnar nerve near the wrist. We present a case of a high combined median and ulnar nerve injury. We performed transfer of the EDM branch and 1 of the branches to the ECU of the PIN to the motor component of the ulnar nerve for intrinsic hand function. RESULTS: Our anatomic data demonstrate the branching pattern of the PIN and the length of regeneration and nerve graft required. Our patient required a 10-cm nerve graft, and the length of regeneration to reach the wrist was 19 cm. The patient recovered useful but incomplete reinnervation of the intrinsic muscles and rated hand recovery at 70%. CONCLUSIONS: Transfer of the EDM and ECU branches of the PIN to the motor component of the ulnar nerve is feasible with the use of a nerve graft. Using some of the branches to the ECU as well increases the axonal load to maximize muscle reinnervation. CLINICAL RELEVANCE: Proximal ulnar nerve injuries with paralysis of the intrinsic hand muscles lead to severe disability. Distal nerve transfers eliminate key factors that result in poor outcomes by allowing for faster muscle reinnervation. This nerve transfer had no functional donor morbidity and could be useful in the setting of a combined high median and ulnar nerve injury.

Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation.

Functional motor recovery after peripheral nerve injury is predominantly determined by the time to motor end plate reinnervation and the absolute number of regenerated motor axons that reach target. Experimental models have shown that axonal regeneration occurs across a supercharged end-to-side (SETS) nerve coaptation. In patients with a recovering proximal ulnar nerve injury, a SETS nerve transfer conceptually is useful to protect and preserve distal motor end plates until the native axons fully regenerate. In addition, for nerve injuries in which incomplete regeneration is anticipated, a SETS nerve transfer may be useful to augment the regenerating nerve with additional axons and to more quickly reinnervate target muscle. We describe our technique for a SETS nerve transfer of the terminal anterior interosseous nerve (AIN) to the pronator quadratus muscle (PQ) end-to-side to the deep motor fascicle of the ulnar nerve in the distal forearm. In addition, we describe our postoperative therapy regimen for these transfers and an evaluation tool for monitoring progressive muscle reinnervation. Although the AIN-to-ulnar motor group SETS nerve transfer was specifically designed for ulnar nerve injuries, we believe that the SETS procedure might have broad clinical utility for second- and third-degree axonotmetic nerve injuries, to augment partial recovery and/or "babysit" motor end plates until the native parent axons regenerate to target. We would consider all donor nerves currently utilized in end-to-end nerve transfers for neurotmetic injuries as candidates for this SETS technique.

Calcaneal reconstruction with free fibular osteocutaneous flap.

Due to the role of the calcaneus in weight bearing, soft tissue coverage along with proper reduction of the fracture is the treatment following open calcaneal injury. Intra-articular calcaneal fractures present a very difficult management problem, as the lack of soft tissue and the intricate vascularity in this area pose a risk of complications. Coverage with local and free muscle flaps following excision of infected structures is a common approach for the treatment of chronic osteomyelitis. However, it is unknown which type of flap is optimal for the treatment of lateral foot wounds, especially when complicated by calcaneal osteomyelitis. A patient presented with an open wound over the lateral aspect of the heel with exposed hardware and chronic osteomyelitis of the calcaneus. Following multiple debridements, an ipsilateral osteocutaneous free fibular flap was transferred to the bony defect. Weight bearing was initiated at 2 months postoperatively, and he now ambulates with a normal gait, has normal plantar sensation, and has no difficulty maneuvering stairs. The patient has done well postoperatively and has recovered full range of motion and complete mobility. In this case report, an osteocutaneous free flap provided an excellent outcome for an active patient with a very complex and complicated condition.

Pancreatic cyst: pseudocyst or neoplasm? Pitfalls in endoscopic retrograde cholangiopancreatography diagnosis.

Pancreatic pseudocysts represent the majority of cystic lesions, and can usually be differentiated from cystic neoplasms, which have malignant potential. Endoscopic retrograde cholangiopancreatography (ERCP) can help in solving diagnostic dilemmas. When ERCP demonstrates cyst communication with the pancreatic duct, the diagnosis of pseudocyst is usually secure. There are exceptions, however, as reported in these two case reports. A retrospective chart review was conducted of two patients undergoing distal pancreatectomy in 2008 to 2009 for cystic lesions communicating with the main pancreatic duct on ERCP. Both patients were women (ages 37 and 42) with a history of chronic abdominal pain and pancreatitis. Radiologic imaging showed cystic lesions in the pancreatic tail. ERCP demonstrated main pancreatic duct communication. When endoscopic management failed, surgical therapy was undertaken. Both patients underwent distal pancreatectomy with splenectomy. Pathologic findings were mucinous cystadenoma. The conventional wisdom that a pancreatic cyst communicating with the main pancreatic duct is a benign pseudocyst is not always wise. As seen in this series, mucinous cystadenomas can erode into the main pancreatic duct. Women in the fourth and fifth decade with symptomatic cysts in the pancreatic tail with a history of pancreatitis should undergo distal pancreatectomy, regardless of ductal communication on ERCP.