Is Tourniquet Pain the Result of Increased Compartment Pressure in the Forearm?

ABSTRACT: The pneumatic tourniquet has been a mainstay in upper extremity surgery by allowing the surgeon to operate in a blood-free field. Many upper extremity surgical procedures are done under local anesthesia or minimal sedation, and the problem of tourniquet pain is a vexing one. The question is posed: Is tourniquet pain the result of increased compartment pressure in the forearm? This study measured compartment pressures of the volar forearm in 10 healthy normotensive volunteers before inflation of a pneumatic tourniquet and compared it with pressure measurements taken while the tourniquet was still inflated after 15 minutes. Compartment pressures were measured using a Stryker needle manometer; all measurements were taken in the volar forearm by the senior author (C.H.M.). There was no increase in the volar/flexor compartment pressure of the forearm after 15 minutes of tourniquet inflation. All subjects complained of pain of the forearm, characteristically what is commonly called "tourniquet pain." We therefore conclude that in the upper extremity, at least for relatively short operating times, appropriate inflation of a tourniquet does not induce the early onset of increased compartment pressure in the forearm.

The N-LVA Study: effectiveness and cost-effectiveness of lymphaticovenous anastomosis (LVA) for patients with cancer who suffer from chronic peripheral lymphoedema - study protocol of a multicentre, randomised sham-controlled trial.

INTRODUCTION: Cancer-related lymphoedema is one of the most debilitating side-effects of cancer treatment with an overall incidence of 15.5%. Patients may suffer from a variety of symptoms, possibly resulting in a diminished health-related quality of life (HRQoL). A microsurgical technique known as lymphaticovenous anastomosis (LVA) might be a promising treatment option. The objective of this study is to evaluate whether LVA is effective and cost-effective compared with sham surgery in improving the HRQoL. METHODS AND ANALYSIS: A multicentre, double-blind, randomised sham-controlled trial conducted in three university hospitals in the Netherlands. The study population comprises 110 patients over the age of 18 years with unilateral, peripheral cancer-related lymphoedema, including 70 patients with upper limb lymphoedema and 40 patients with lower limb lymphoedema. A total of 55 patients will undergo the LVA operation, while the remaining 55 will undergo sham surgery. The follow-up will be at least 24 months. Patients are encouraged to complete the follow-up by explaining the importance of the study. Furthermore, patients may benefit from regular monitoring moments for their lymphoedema. The primary outcome is the HRQoL. The secondary outcomes are the limb circumference, excess limb volume, changes in conservative therapy, postoperative complications, patency of the LVA and incremental cost-effectiveness. ETHICS AND DISSEMINATION: The study was approved by the Medical Ethical Committee of Maastricht University Medical Center on 20 September 2023 (NL84169.068.23). The results will be presented at scientific conferences and published in peer-reviewed medical journals. TRIAL REGISTRATION NUMBER: NCT06082349.

The effect of time from injury to fasciotomy in patients with acute upper extremity compartment syndrome.

BACKGROUND: Acute compartment syndrome of the upper extremity is a surgical emergency, and timely diagnosis with immediate fasciotomies is essential for the preservation of function. This retrospective study aimed to compare the complication rates of patients who underwent fasciotomy before and after 6 hours following the initial trauma. METHODS: The medical records of the patients who underwent fasciotomy for surgical treatment of ACS of the upper extremity between 2016 and 2022 were retrospectively analyzed for age, gender, dominant hand, mechanism of injury, injury level, affected compartments, associated injuries, time elapsed till fasciotomy, and complications. The patients were divided into two groups according to the timing of fasciotomy. RESULTS: A total of 32 patients underwent fasciotomies for upper extremity ACS. The mean age of patients who underwent fasciotomy ≤ 6 hours (group 1; 10 males, 7 females) and patients who underwent fasciotomy > 6 hours (group 2; 13 males, 2 females) was 31.1 and 34.8, respectively. The most common etiology was crushing injury. There was a significant difference in complication rates between group 1 (1/17) and group 2 (10/15) (p<0.001). The length of hospitalization stay in group 2 was statistically higher than in group 1 (p=0.005). CONCLUSION: Fasciotomies for ACS of the upper extremity should be performed in less than 6 hours following the initial trauma to prevent complications.

Socioeconomic factors and outcome after repair and reconstruction of digital and major nerve trunk injuries in the upper limb.

Peripheral nerve injuries in the upper limb can lead to substantial disability and pain. We aimed to assess how socioeconomic factors affect outcomes after repaired or reconstructed digital or major nerve trunk injuries in the upper limb. We identified 670 individuals, who underwent surgical nerve repair or reconstruction using sensory nerve autografts, in the Swedish National Quality Registry for Hand Surgery 2010-2018. Socioeconomic factors, including education, cohabitation, type of work, sick leave, immigrant status and income, were gathered from the Swedish statistical agency ( www.scb.se ) and National Diabetes Register (NDR). We calculated prevalence ratios (PR) to assess the relationship between socioeconomic factors and surgical outcomes for the nerve injuries. Individuals with a major nerve trunk injury had higher QuickDASH scores and lower income compared to those with digital nerve injury. Individuals with immigration background (adjusted PR = 2.0, 95% CI 1.2-3.2), history of > 4 weeks of sick leave the year before surgery (adjusted PR = 1.8, 95% CI 1.1-3.1), or education level below tertiary (adjusted PR = 2.8, 95% CI 1.7-4.7) had significantly higher QuickDASH scores. Recognizing impact of non-biological factors, including immigration, prior sick leave, and education level, on outcome after nerve surgery is crucial for improving prognosis in socioeconomically deprived individuals.

Cervical dorsal rhizotomy for upper limbs spasticity. Case report.

Spasticity is a prevalent symptom of upper motor neuron syndrome, becoming debilitating when hindering voluntary movement and motor function and causing contractures and pain. Functional neurosurgery plays a crucial role in treating severe spasticity. Despite extensive literature on SDR for lower limb spasticity, there is a scarcity of papers regarding the procedure in the cervical region to alleviate upper limb spasticity. This case report details a cervical dorsal rhizotomy (CDR) performed for upper limb spasticity, resulting in significant improvement in spasticity with sustained outcomes and low complication rates. Neuroablative procedures like CDR become an option to treat spasticity.

Recent Advances in Upper Extremity Microsurgery: From Traditional to Perforator Flaps.

The upper extremity has unique functional and aesthetic requirements. Reconstruction of upper extremity soft tissue defects should ideally provide coverage for vital structures, facilitate early mobilization, be thin and pliable to match its slim contour, and reestablish sensation. Perforator flaps can be raised on the superficial fascia, which creates a thin and pliable yet durable and supple flap option to match the contour and functional needs of the upper extremity. Comparisons to traditional reconstructive methods should be performed to assess whether these innovations in microsurgical reconstruction of upper extremity defects provide an improved functional and aesthetic benefit over traditional methods.

Evolution and Application of Ultrasound for Flap Planning in Upper Extremity Reconstruction.

Accurate preoperative localization of dominant perforators provides crucial information about their location and diameter, leading to reduced surgical time, improved flap viability, and decreased complications. Ultrasound has increased in popularity in recent years, with the advantages of providing reproducible, accurate, cost-effective, and real-time information while reducing radiation exposure. Precise preoperative mapping of perforators allows for rapid and safe elevation of suprafascial, thin, and superthin flaps. This review focuses on the role of ultrasound as a tool for preoperative flap planning in the upper extremities.

Thin Profunda Artery Perforator Flap for Hand and Upper Extremity Coverage.

The profunda artery perforator (PAP) flap provides a good option for hand and upper extremity reconstruction. The reliable quality, caliber, and number of perforators in the posteromedial thigh support large flaps with long pedicles. The PAP flap has been widely used for breast reconstruction, although its use in the extremities has been slower to catch on due to the bulk and thickness of the subcutaneous tissue. The authors discuss evolution of thin flaps and our application of the thin and superthin PAP flap for upper extremity reconstruction.

Superficial Circumflex Iliac Artery Perforator Flap Reconstruction of the Upper Extremity.

The superficial circumflex iliac artery perforator (SCIP) flap is thin, pliable tissue well suited for reconstruction of injuries of the hand and upper extremity. Based upon perforators from the superficial circumflex iliac artery, the SCIP flap has advantages over the traditional groin flap due to reduced need for secondary procedures and improved donor site morbidity This article offers a detailed exploration of the SCIP flap design and technique, its advantages over traditional methods, and its potential applications in reconstructive surgery. Post-operative care and critical points are also discussed, and case examples are provided to guide readers through the intricacies of the technique, emphasizing the surgical skill and precision required for successful implementation.

Thin and Thinned Anterolateral Thigh Flaps for Upper Extremity Reconstruction.

Upper extremity reconstruction remains challenging due to the high functional and esthetic demands of this location. The anterolateral thigh (ALT) flap is a workhorse flap for microsurgical reconstruction of the upper extremity and can be elevated in various planes depending on desired thickness of the flap. Microsurgical reconstruction of the upper extremity often benefits from a thin flap that can resurface the extremity, which can provide improved functional and esthetic outcomes. This article reviews the anatomy, preoperative planning, and operative technique, as well as presents 4 cases to illustrate the outcomes and benefits of thin and thinned ALT flaps.

Evolution and Diversity of Medial Sural Artery Perforator Flap for Hand Reconstruction.

The free medial sural artery perforator (MSAP) flap is a recently popularized flap. It has evolved from a composite myocutaneous flap to a pedicled perforator flap for lower limb reconstruction. It is also a versatile free perforator flap for extremity and head and neck reconstruction. The diversity of the flap designs with options for harvest of non-vascularized grafts enhances the versatility for hand and upper limb reconstruction. The adjunctive use of endoscopy and indocyanine green fluorescence imaging studies can assist and demystify the flap anatomy. The authors present their experience using free MSAP flaps for complex mutilated hand and upper extremity reconstruction.

Surgical Treatment of Lymphedema in the Upper Extremity.

The advent of supermicrosurgery has led to an increasing interest in the surgical management of lymphedema through the reconstruction of the lymphatic network, that is, the physiologic approach. Broadly, this can be divided into 2 main techniques: lymphaticovenous anastomosis and lymph node transfer. In the United Kingdom, the British Lymphology Society does not provide any recommendations on surgical management. Moreover, surgical treatment of lymphedema is not widely practiced within the National Health Service due to low-certainty evidence. Herein, we discuss our experience in physiologic reconstruction for lymphedema.

Alternative Flap Options for Upper Extremity Reconstruction.

For major upper limb defects, a wide range of established pedicled and free flap options can be used. These include the latissimus dorsi/thoracodorsal artery perforator, lateral arm, posterior interosseous artery, rectus abdominis, gracilis, and anterolateral thigh flaps. Technical proficiency is essential, and favorable success rates in terms of functional and esthetic outcomes can be achieved. Herein, alternative flap options (both pedicled and free) are introduced and discussed through a few illustrative case examples.

The Role of 3D Custom Implants in Upper Extremity Surgery.

SUMMARY: As the technology of three-dimensional (3D) printing becomes more refined and accessible, multiple applications of its use are becoming more commonplace in upper extremity surgery. 3D-printed models have been beneficial in preoperative planning of complex cases of acute trauma or malunions, contributing to spatial understanding or even contouring of implants. Custom guides can also be created to assist intraoperatively with precise placement of osteotomies or arthroplasty implants. Finally, custom 3D implants have been described for cases of bone loss in the upper extremity. This can be for relatively small gaps after malunion correction or extensive defects, typically for trauma or tumor. Articular defects can also be addressed with this technology, although special considerations should be given to the implant design and longevity in these situations. Because of the relatively recent nature of 3D implants, long-term data are lacking. However, they show great promise in an expanding range of challenging clinical indications.

[Selective Neurectomy in Spastic Paralysis of the Upper Extremity]. / Die hyperselektive Neurektomie bei spastischen Lähmungen der oberen Extremität.

Selective neurectomy refers to the targeted transection of motor nerve fibres at their entry into the muscle in order to reduce the increased muscle tone in cases of spastic paralysis. This procedure has regained popularity in recent years, especially in the upper extremity. First and foremost, it requires an exact knowledge of the topographical anatomy of muscle innervation. To be able to control the extent and localisation of the denervation, the terminal nerve branches must be visualized precisely during the procedure. For a meaningful reduction of muscle tone, 2/3 to 4/5 of nerve fibres must be resected. This article presents the historical development, principles and operative details of this technique as well as clinical results.

[Nerve Transfers in Children with Non-traumatic Amyoplasia] / Nerventransfers bei Kindern mit nicht traumatischer AmyoplasieNerve Transfers in Children with Non-traumatic Amyoplasia.

BACKGROUND: The treatment of obstetric brachial plexus palsy through primary reconstruction and nerve transfers has been established in the past decades. In the case of non-traumatic diseases that lead to flaccid paralysis and the inability to move the extremities, such as transverse myelitis (TM) or arthrogryposis multiplex congenita (AMC), which can have a wide variety of causes, the focus has been on rehabilitative therapy so far, while surgical interventions have been used to a lesser extent, e. g., in the form of osteotomies or muscle transfers. Our aim is to establish nerve transfers as a surgical option to improve mobility in non-traumatic amyoplasia. PATIENTS: This work presents the needs-adapted treatment of a total of 23 patients (aged 4 months to 64 months, 18 with AMC and 5 with TM) using nerve transfers on the upper extremity. RESULTS: We were able to show that early nerve transfers in the upper extremity enabled the reanimation of muscles in both AMC and TM. CONCLUSION: This work shows that the treatment of non-traumatic amyoplasia in children with selective nerve grafts is a successful method. Nerve transfers allow patients to gain or regain important functions for managing independent everyday life. The surgical methods have been established in the treatment of traumatic nerve injuries. They are well-known and can be carried out safely. We believe that this is an important treatment option for paediatric patients with paralysis associated with TM or AMC, which should also be known to the treating physicians.

[Clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury].

Objective: To investigate the clinical effect of anterolateral thigh flow-through chimeric perforator free flap transplantation in the treatment of upper limb complex tissue defects with main artery injury. Methods: The study was a retrospective observational study. From May 2019 to January 2022, 11 patients with upper limb complex tissue defects combined with main artery injury who met the inclusion criteria were admitted to the Department of Hand, Foot and Ankle Surgery of General Hospital of Ningxia Medical University, including 7 males and 4 females, aged from 18 to 56 years. After debridement, the area of skin and soft tissue defects was from 20 cm×6 cm to 32 cm×10 cm, and the exposed area of dead cavity or deep tissue was from 7 cm×4 cm to 10 cm×7 cm. Three patients had radial artery defects with a length of 4 to 7 cm; two patients had ulnar artery defects with a length of 5 to 8 cm; 4 patients had defects in both ulnar and radial arteries with a length of 3 to 7 cm; and in two patients, the ulnar, radial and brachial arteries were all defective with a length of 4 to 8 cm. The anterolateral thigh flow-through chimeric perforator flap was designed and cut. The skin flap area was from 22 cm×7 cm to 32 cm×11 cm, the chimeric muscle flap area was from 7 cm×4 cm to 10 cm×7 cm, and the length of the flow-through vessel in the "T" shaped vessel pedicle was from 4 to 8 cm. When transplanting the skin flap, the proximal end of the vascular pedicle was anastomosed with the proximal end of the recipient site, and the distal end of the vascular pedicle was anastomosed with the more normal blood vessel at the distal end of the forearm; the invalid cavity was filled with the muscle flap. The donor site wounds of tissue flap were closed directly or treated with skin grafting. After operation, the blood supply and survival of the flap, the survival of the distal limb, and the survival of the skin graft at the flap donor site were observed. Computed tomography angiography (CTA) was performed to observe the patency of the proximal and distal anastomotic arteries from 2 to 4 weeks after surgery. During follow-up, the texture of the flap, the survival of the grafted skin and the healing of the donor area were observed. Results: One patient (complete forearm disconnection) developed distal limb blood disorder on 5 days after surgery. CTA examination suggested embolization of the distal anastomosis of the flow-through artery. more muscle and skin and soft tissue necrosis of the distal limb showed in emergency exploration. So, amputation was performed ultimately. No vascular crisis occurred in the skin flaps of the remaining 10 patients, and all skin flaps, distal limbs and the skin grafts in flap donor sites survived well. Two to 4 weeks after surgery, the proximal and distal ends of the anastomosed arteries were good in the patency. Follow-up for 11-37 months, the flap texture was good, and all donor site wounds healed well. Conclusions: The use of anterolateral thigh flow-through chimeric perforator flap to repair upper limb complex tissue defects accompanied by main artery injury can improve the success rate of limb salvage, which can be promoted in clinical practice.

[Nerve Transfers in Peripheral Nerve Lesions]. / Nerventransfers bei peripheren Nervenläsionen.

BACKGROUND: Lesions of peripheral nerves of the upper extremities often lead to persistent, serious limitations in motor function and sensory perception. Affected patients suffer from both private and professional restrictions associated with long-term physical, psychological and socioeconomic consequences. INDICATION: An early indication for a nerve transfer shortens the reinnervation distance and improves the growing of motor and sensory axons into the target organ to facilitate early mobility and sensitivity. When planning the timepoint of the surgical procedure, the distance to be covered by reinnervation as well as the morbidities of donor nerves must be considered individually. RESULTS: Nerve transfers can achieve earlier and safer reinnervation to improve motor and sensory functions after nerve injuries in the upper extremity.

[Prosthetic Fitting Concepts after Major Amputation in the Upper Limb - an Overview of Current Possibilities]. / Prothetische Versorgungskonzepte nach Majoramputation der oberen Extremität ­ eine Übersicht gegenwärtiger Möglichkeiten.

BACKGROUND: The upper extremity and particularly the hands are crucial for patients in interacting with their environment, therefore amputations or severe damage with loss of hand function significantly impact their quality of life. In cases where biological reconstruction is not feasible or does not lead to sufficient success, bionic reconstruction plays a key role in patient care. Classical myoelectric prostheses are controlled using two signals derived from surface electrodes in the area of the stump muscles. Prosthesis control, especially in high amputations, is then limited and cumbersome. The surgical technique of Targeted Muscle Reinnervation (TMR) offers an innovative solution: The major arm nerves that have lost their target organs due to amputation are rerouted to muscles in the stump area. This enables the establishment of cognitive control signals that allow significantly improved prosthesis control. PATIENTS/MATERIALS AND METHODS: A selective literature review on TMR and bionic reconstruction was conducted, incorporating relevant articles and discussing them considering the clinical experience of our research group. Additionally, a clinical case is presented. RESULTS: Bionic reconstruction combined with Targeted Muscle Reinnervation enables intuitive prosthetic control with simultaneous movement of various prosthetic degrees of freedom and the treatment of neuroma and phantom limb pain. Long-term success requires a high level of patient compliance and intensive signal training during the prosthetic rehabilitation phase. Despite technological advances, challenges persist, especially in enhancing signal transmission and integrating natural sensory feedback into bionic prostheses. CONCLUSION: TMR surgery represents a significant advancement in the bionic care of amputees. Employing selective nerve transfers for signal multiplication and amplification, opens up possibilities for improving myoelectric prosthesis function and thus enhancing patient care. Advances in the area of external prosthetic components, improvements in the skeletal connection due to osseointegration and more fluid signal transmission using wireless, fully implanted electrode systems will lead to significant progress in bionic reconstruction, both in terms of precision of movement and embodiment.