The Medial Antebrachial Cutaneous Nerve Is a Low-Morbidity Alternative to the Standard Sural Nerve Autograft.

BACKGROUND: Nerve interposition grafting is an important technique in nerve reconstructive surgery that is used when a primary repair is not feasible without significant tension. This study sought to evaluate the long-term morbidity of the medial antebrachial cutaneous (MABC) nerve as an alternative donor nerve in comparison with sural nerve harvest. METHODS: A single surgeon and institution retrospective chart review was performed to identify all patients who underwent nerve autografting using the sural and MABC as donor nerves between January 1, 2000 and December 31, 2019. Surveys assessed overall patient satisfaction with surgery, as well as donor and recipient site morbidity, satisfaction, pain, numbness, and cold sensitivity. RESULTS: Of the 73 patients contacted, 54 agreed to participate, and 43 of 73 (58.9%) ultimately completed the survey: 28 MABC (65.1%) and 15 sural (34.9%). There were no significant differences between the sural and MABC groups in overall satisfaction with surgery, donor and recipient site satisfaction, pain, cold sensitivity, and effect on quality of life. Even though 66.7% of sural donor sites and 75% of MABC donor sites had residual numbness, the effect this had on quality of life was very low (2 and 3, respectively). CONCLUSION: The MABC is a safe alternative to the traditional sural nerve autograft. A small subset of patients undergoing nerve autograft harvest will experience long-term morbidity in the form of pain. Conversely, the more common presence of numbness is not reported as bothersome.

Assessment, patient selection, and rehabilitation of nerve transfers.

Peripheral nerve injuries are common and can have a devastating effect on physical, psychological, and socioeconomic wellbeing. Peripheral nerve transfers have become the standard of care for many types of peripheral nerve injury due to their superior outcomes relative to conventional techniques. As the indications for, and use of, nerve transfers expand, the importance of pre-operative assessment and post-operative optimization increases. There are two principal advantages of nerve transfers: (1) their ability to shorten the time to reinnervation of muscles undergoing denervation because of peripheral nerve injury; and (2) their specificity in ensuring proximal motor and sensory axons are directed towards appropriate motor and sensory targets. Compared to conventional nerve grafting, nerve transfers offer opportunities to reinnervate muscles affected by cervical spinal cord injury and to augment natural reinnervation potential for very proximal injuries. This article provides a narrative review of the current scientific knowledge and clinical understanding of nerve transfers including peripheral nerve injury assessment and pre- and post-operative electrodiagnostic testing, adjuvant therapies, and post-operative rehabilitation for optimizing nerve transfer outcomes.

Quantifying Tenodesis Hand Function in Cervical Spinal Cord Injury: Implications for Function.

PURPOSE: Cervical spinal cord injury (SCI) has a profound effect on upper-extremity function. Individuals with stiffness and/or spasticity may have more, or less, useful tenodesis function. This study examined the variability present before any reconstructive surgery. METHODS: Tenodesis pinch and grasp were measured with the wrist in maximal active extension. Tenodesis pinch was the contact point of the thumb with the index finger proximal phalanx (T-IF:P1), middle phalanx (T-IF:P2), distal phalanx (T-IF:P3), or absent (T-IF:absent). Tenodesis grasp was the distance from the long finger to the distal palmar crease (LF-DPC). Activities of daily living function was assessed using the Spinal Cord Independence Measure (SCIM). RESULTS: The study included 27 individuals (4 females, 23 males; mean age 36 years, mean time since SCI 6.8 years). The mean International Classification for Surgery of the Hand in Tetraplegia (ICSHT) group classification was 3. In the dominant hand, individuals with a T-IF tenodesis pinch to P1 or P2 had significantly higher total SCIM scores (43.7 and 34.2, respectively) compared to those with absent T-IF tenodesis pinch (SCIM 17.8). Shorter LF-DPC distance with tenodesis grasp (improved finger closing) also correlated with improved SCIM mobility and total scores. No association was found between the ICSHT group and SCIM score or tenodesis measures. CONCLUSIONS: Quantifying tenodesis with pinch (T-IF) and grasp (LF-DPC) is a simple method to characterize hand movement in individuals with cervical SCI. Better tenodesis pinch and grasp were associated with improved activities of daily living performance. CLINICAL RELEVANCE: Differences in grasp function have implications for mobility, and differences in pinch function have implications for all functions, particularly self-care. These physical measurements could be used to assess movement changes after nonsurgical and surgical treatment in tetraplegia.

Abductor Digiti Minimi and Anterior Interosseous to Ulnar Motor Nerve Transfer: The Super Turbocharge End-to-Side Transfer.

SUMMARY: Anterior interosseous nerve to ulnar motor nerve supercharged end-to-side (SETS) nerve transfer to restore intrinsic function is a recently adopted nerve transfer in severe ulnar neuropathy. Its success is predicated on the critical threshold number of axons innervating the intrinsic muscles. Given the relative expendability of the abductor digiti minimi (ADM) muscle and the critical function of the other intrinsic muscles, the authors modified their SETS transfer to redirect axons from the ADM to turbocharge the ulnar motor nerve to innervate the more critical intrinsic muscles. They refer to this procedure as a super turbocharged end-to-side (STETS) procedure. The ADM has been used previously as a muscle/tendon transfer for thumb opposition and more recently as a nerve transfer to reinnervate the thenar branch of the median nerve. Although current methods of assessment of reinnervation are likely unable to differentiate between contributions from the anterior interosseous nerve SETS versus ADM STETS transfer, this technique follows the fundamentals of modern nerve surgery, where directing the maximum number of nerve fibers in a timely fashion to the most critical target is paramount for the best functional recovery. The authors suggest that the STETS technique may optimize outcomes in ulnar neuropathy without additional patient morbidity.

A Surgical Framework for the Management of Incomplete Axillary Nerve Injuries.

BACKGROUND: Axillary nerve injury is the most common nerve injury affecting shoulder function. Nerve repair, grafting, and/or end-to-end nerve transfers are used to reconstruct complete neurotmetic axillary nerve injuries. While many incomplete axillary nerve injuries self-resolve, axonotmetic injuries are unpredictable, and incomplete recovery occurs. Similarly, recovery may be further inhibited by superimposed compression neuropathy at the quadrangular space. The current framework for managing incomplete axillary injuries typically does not include surgery. METHODS: This study is a retrospective analysis of 23 consecutive patients with incomplete axillary nerve palsy who underwent quadrangular space decompression with additional selective medial triceps to axillary end-to-side nerve transfers in 7 patients between 2015 and 2019. Primary outcome variables included the proportion of patients with shoulder abduction M3 or greater as measured on the Medical Research Council (MRC) scale, and shoulder pain measured on a Visual Analogue Scale (VAS). Secondary outcome variables included pre- and postoperative Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) scores. RESULTS: A total of 23 patients met the inclusion criteria and underwent nerve surgery a mean 10.7 months after injury. Nineteen (83%) patients achieved MRC grade 3 shoulder abduction or greater after intervention, compared with only 4 (17%) patients preoperatively (p = 0.001). There was a significant decrease in VAS shoulder pain scores of 4.2 ± 2.5 preoperatively to 1.9 ± 2.4 postoperatively (p < 0.001). The DASH scores also decreased significantly from 48.8 ± 19.0 preoperatively to 30.7 ± 20.4 postoperatively (p < 0.001). Total follow-up was 17.3 ± 4.3 months. CONCLUSION: A surgical framework is presented for the appropriate diagnosis and surgical management of incomplete axillary nerve injury. Quadrangular space decompression with or without selective medial triceps to axillary end-to-side nerve transfers is associated with improvement in shoulder abduction strength, pain, and DASH scores in patients with incomplete axillary nerve palsy.

Interpreting Electrodiagnostic Studies for the Management of Nerve Injury.

Nerve injuries are common after trauma and can be life-altering for patients. Electrodiagnostic studies are the gold standard for diagnosing and prognosticating nerve injuries. However, most surgeons are not trained in the interpretation of these studies; rather, they rely on the interpretation provided by the electrodiagnostician, who in turn is unlikely to be trained in nerve reconstruction. This discrepancy between the interpretation of these studies and the management of nerve injuries can lead to suboptimal surgical planning and patient outcomes. This review aims to provide a framework for surgeons to take a more active role in collaborating with their colleagues in electrodiagnostic medicine in the interpretation of these studies, with an ultimate goal of improved patient care. The basics of nerve conduction studies, electromyography, and relevant terminology are reviewed. The relationship between the concepts of demyelination, axon loss, Wallerian degeneration, nerve regeneration, collateral sprouting, and clinical function are explained within the framework of the Seddon and Sunderland nerve injury classification system. The natural evolution of each degree of nerve injury over time is illustrated, and management strategies are suggested.

Failed Targeted Muscle Reinnervation: Findings at Revision Surgery and Concepts for Success.

Although it was initially described for improved myoelectric control, targeted muscle reinnervation (TMR) has quickly gained popularity as a technique for neuroma control. With this rapid increase in utilization has come broadening indications and variability in the described technique. As a result, it becomes difficult to interpret published outcomes. Furthermore, there is no literature discussing the management of failed cases which are undoubtedly occurring. Methods: This is a retrospective case series of two patients who underwent revision surgery for failed TMR. The authors also review the current literature on TMR and outline technical and conceptual pitfalls and pearls based on our local experience. Results: Excessive donor nerve redundancy, kinking, donor-recipient nerve size mismatch, superficial placement of the nerve coaptation, inappropriate target selection, and incomplete target muscle denervation were identified as technical pitfalls of TMR surgery. Techniques to avoid these pitfalls were described. Conclusions: Although TMR has been a major development in amputee care for both pain management and improved myoelectric control, it is important to acknowledge that it is not a foolproof surgery and does not provide a guaranteed result. Failed cases of TMR represent opportunities to learn about factors contributing to unfavorable outcomes and refine our techniques empirically.

Revision of Carpal Tunnel Surgery.

Carpal tunnel release is one of the most commonly performed upper extremity procedures. The majority of patients experience significant improvement or resolution of their symptoms. However, a small but important subset of patients will experience the failure of their initial surgery. These patients can be grouped into persistent, recurrent, and new symptom categories. The approach to these patients starts with a thorough clinical examination and is supplemented with electrodiagnostic studies. The step-wise surgical management of revision carpal tunnel surgery consists of the proximal exploration of the median nerve, Guyon's release with neurolysis, the rerelease of the transverse retinaculum, evaluation of the nerve injury, treatment of secondary sites of compression, and potential ancillary procedures. The approach and management of failed carpal tunnel release are reviewed in this article.

Complete Foot Drop With Normal Electrodiagnostic Studies: Sunderland "Zero" Ischemic Conduction Block of the Common Peroneal Nerve.

ABSTRACT: Common peroneal neuropathy is a peripheral neuropathy of multifactorial etiology often left undiagnosed until foot drop manifests and electrodiagnostic abnormalities are detected. However, reliance on such striking symptoms and electrodiagnostic findings for diagnosis stands in contrast to other commonly treated neuropathies, such as carpal tunnel and cubital tunnel syndrome. Poor recognition of common peroneal neuropathy without foot drop or the presence of foot drop with normal electrodiagnostic studies thus often results in delayed or no surgical treatment. Our cases document 2 patients presenting with complete foot drop who had immediate resolution after decompression. The first patient presented with normal electrodiagnostic studies representing an isolated Sunderland Zero nerve ischemia. The second patient presented with severe electrodiagnostic studies but also had an immediate improvement in their foot drop representing a Sunderland VI mixed nerve injury with a significant contribution from an ongoing Sunderland Zero ischemic conduction block. In support of recent case series, these patients demonstrate that common peroneal neuropathy can present across a broad diagnostic spectrum of sensory and motor symptoms, including with normal electrodiagnostic studies. Four clinical subtypes of common peroneal neuropathy are presented, and surgical decompression may thus be indicated for these patients that lack the more conventional symptoms of common peroneal neuropathy.

Destination Design msTRAM: For Greater Reconstructive Certainty.

Performing delayed reconstruction to a unilateral breast while simultaneously performing a balancing procedure on the contralateral side can be the most difficult situation to achieve symmetry. We present here a novel approach to free TRAM-based breast reconstruction using reverse planning and subunit principles with simultaneous balancing reduction mastopexy and immediate nipple reconstruction. METHODS: A retrospective chart review and a BREAST-Q questionnaire of a single surgeon's practice was performed to compare revision rates and patient satisfaction following Destination Design msTRAM reconstruction compared with a historical cohort of patients who received traditional free TRAM reconstruction. RESULTS: The chart review identified 39 patients treated with the traditional unilateral technique from 1997 to 2004 and 88 patients treated with the novel unilateral technique from 2004 to 2017. Traditional technique patients had a breast revision rate of 64.1% and a nipple revision rate of 42.3% after secondary nipple reconstruction. Destination Design patients had a breast revision rate of 44.3% (P = 0.0394) and a nipple revision rate of 37.9% (P = 0.689) after primary nipple reconstruction. The BREAST-Q questionnaire was sent to nine traditional technique patients with 8 responses (89%), and 35 Destination Design patients with 25 responses (71%). Survey results showed that traditional technique and Destination Design patients had an overall breast satisfaction rate of 67.5% and 63.9%, respectively. CONCLUSIONS: The Destination Design msTRAM breast reconstruction technique leads to a statistically significant reduction in breast flap revisions, and allows for equally accurate immediate nipple reconstruction compared with traditional methods with no additional complications. Overall patient satisfaction is comparable with both techniques.

The Keystone Flap-A Case Series Demonstrating Practical Design, Use, and Applications.

INTRODUCTION: The keystone design perforator island flap is a trapezoidal-shaped random perforator island flap with many advantages over primary closure, skin grafting, and other local flaps for soft tissue reconstruction commonly encountered with cancer excisions. METHODS: This case series of 39 keystone flaps in 37 patients reviews the practical design, use, and applications of the flap while highlighting certain important considerations. Keystone flaps were designed as in the original description, with a minor modification in the lower extremity where a higher flap to defect width ratio was used. RESULTS: Defects varying in size from 6 to 63 cm2 were reconstructed in 23 males and 14 females ranging in age from 49 to 89. In all 39 cases, there were 2 minor complications of partial flap dehiscence and no major complications such as partial or complete flap loss. CONCLUSION: The keystone flap is a versatile and reliable flap with applications almost anywhere on the body. A higher ratio of flap width to defect width up to 1:3 is more appropriate for the lower extremity where tension is higher.

INTRODUCTION: Le lambeau en clef de voûte perforateur en îlot est un lambeau perforateur trapézoïdal aléatoire qui comporte de nombreux avantages par rapport à la fermeture primaire, à la greffe cutanée et à d'autres lambeaux locaux pour la reconstruction des tissus mous souvent nécessaire après des excisions attribuables au cancer. MÉTHODOLOGIE: Cette série de 39 lambeaux en clef de voûte chez 37 patients vise à analyser la conception, l'utilisation et les applications pratiques du lambeau tout en explorant certains aspects importants. Les lambeaux en clef de voûte ont été conçus comme dans la description originale, à part une légère modification dans les membres inférieurs, où les plasticiens ont privilégié un ratio plus élevé entre la largeur du lambeau et la largeur de l'anomalie. RÉSULTATS: Les plasticiens ont reconstruit des anomalies de 6 cm2 à 63 cm2 chez 23 hommes et 14 femmes de 49 à 89 ans. Dans ces 39 cas, ils ont observé deux complications mineures de déhiscence partielle du lambeau et aucune complication majeure, telle que la perte partielle ou totale du lambeau. CONCLUSIONS: Le lambeau en clef de voûte, polyvalent et fiable, peut être utilisé pratiquement partout sur le corps. Un ratio plus élevé pouvant atteindre 1:3 entre la largeur du lambeau et la largeur de l'anomalie convient mieux aux membres inférieurs, où la tension est plus importante.

Split thickness skin graft meshing ratio indications and common practices.

BACKGROUND: Split thickness skin grafting is a commonly used technique in burn surgery for resurfacing wounds that are unlikely to heal without scarring. Meshing and expanding skin grafts allow for reconstruction of larger wounds with smaller donor sites. METHODS: A retrospective chart review was performed of 210 patients with burns equal to or greater than 20% total body surface area admitted to Vancouver General Hospital between 1998 and 2014. Charts were reviewed to collect data on patient and burn demographics. A survey was sent to Canadian plastic surgeons registered with the CSPS to collect data on common practices in burn surgery nationwide. RESULTS: The patients that received 3:1 or higher meshed grafts were all flame burns, had a significantly higher average TBSA (51.89%±14.87 vs 29.13%±9.48, p=0.001), and a significantly higher full thickness burn TBSA (25.76%±21.97 vs 6.20%±9.04, p=0.001). We found no significant differences in gender, age, or burn location between the less than 2:1 and 3:1 or greater meshing ratio groups. The survey of plastic surgeons performing burn surgery in Canada revealed that 60% of responders had experience with skin grafts using meshing ratios of 3:1 or higher. Of these surgeons, 100% felt that burn size and 36% felt that burn location would influence their decision to use a 3:1 or higher meshing ratio. CONCLUSIONS: A larger burn size is the major influencing factor for the use of higher skin graft meshing ratios by Canadian burn surgeons. Furthermore, burn location determines the choice of donor and recipient sites in these cases.

Cholecystocutaneous fistula after percutaneous gallbladder drainage.

Cases of cholecystocutaneous fistulas are now a rare occurrence as a result of rapid diagnosis and treatment. We present a case of cholecystocutaneous fistula developing after the removal of a percutaneous drain for the treatment of acute cholecystitis. Re-occurring infection and presence of gallstones led to fistulization of the gallbladder fundus and the development of a tract along the path created by the drain. The patient presented with re-occurring right upper quadrant abdominal pain, purulent discharge from the fistulous opening and expulsion of multiple gallstones. She underwent laparoscopic cholecystectomy and fistula excision.

Evaluation of essential clinical components and features of current acne global grading scales.

BACKGROUND: Acne research is hindered by the absence of a universal, consistently applied standard for severity grading. Acne experts recently identified 4 essential clinical components and 2 features for an ideal acne global grading scale (AGGS). OBJECTIVE: This study evaluated current AGGSs against consensus criteria previously identified as necessary. METHODS: AGGSs were identified by systematic literature search and then evaluated independently by 4 raters against criteria (components and subcomponents; features and subfeatures) identified as essential. RESULTS: Eighteen AGGSs fulfilled selection criteria. Three scored 1 full SD above the mean for categorical scores. We also identified highest-ranked AGGSs for subcategory scores. LIMITATIONS: Only English-language scales were selected. Efficiency and acceptance were not evaluable. CONCLUSION: Although no singular scale fulfilled all essential criteria, this study did identify highly ranked AGGSs. Incorporation and rationalization of their components and features should facilitate development of an ideal standard.

Effect of point mutations on the secondary structure and membrane interaction of antimicrobial peptide anoplin.

Anoplin (GLLKRIKTLL-NH(2)) is the smallest linear α-helical antimicrobial peptide found naturally to date. Antibacterial and hemolytic properties of anoplin depend strongly on physicochemical properties. Two anoplin derivatives, anoplin-8K (Ano8K, GLLKTIKKLL-NH(2)) and anoplin-1K5 V8K (Ano1K5 V8K, KLLKVIKLL-NH(2)), were found to have increased bacterial and low hemolytic activity. In the present work physicochemical properties of these three peptides were studied by UV resonance Raman (UVRR) spectroscopy, Langmuir-Blodgett monolayer technique, and carboxyfluorescein (CF) leakage assay. UVRR data indicated that all three peptides adopt predominantly unordered conformation in aqueous buffer solution. In membrane-mimicking trifluoroethanol, the α-helical content increases for all three peptides with Ano1K5 V8K having the highest α-helix percentage, followed by Ano8K and anoplin. Critical micelle concentrations were found to be similar for all three peptides, and the saturation pressure decreases in the sequence Ano1K5 V8K, anoplin, Ano8K. Critical pressure of insertion was found to be greater for anionic lipid monolayer DPPG than for zwitterionic lipid DPPC indicating preferential adsorption of all three peptides to DPPG. Finally, membrane lytic activities of all three peptides toward various model lipid vesicles were compared through CF leakage assay. Overall the data indicate that antimicrobial activity of anoplin increases with charge, whereas membrane lytic activity correlates with peptides helicity and amphipathicity.