Identifying Common Peroneal Neuropathy before Foot Drop Lu, Johnny Chuieng-Yi; Dengler, Jana; Poppler, Louis H ...
Plastic and reconstructive surgery (1963),
2020-September, 2020-09-00, 20200901, Letnik:
146, Številka:
3
Journal Article
Recenzirano
BACKGROUND:Common peroneal neuropathy shares the same pathophysiology as carpal tunnel syndrome. However, management is often delayed because of the traditional misconception of recognizing foot drop ...as the defining symptom for diagnosis. The authors believe recognizing common peroneal neuropathy before foot drop can relieve pain and help improve quality of life.
METHODS:One hundred eighty-five patients who underwent surgical common peroneal neuropathy decompression between 2011 and 2017 were included. The mean follow-up time was 249 ± 28 days. Patients were classified into two stages of severity based on clinical presentationpre–foot drop and overt foot drop. Demographics, presenting symptoms, clinical signs, electrodiagnostic studies and response to surgery were compared between these two groups. Multivariate regression analysis was used to identify variables that predicted outcome following surgery.
RESULTS:Overt foot drop patients presented with significantly lower preoperative motor function (percentage of patients with Medical Research Council grade ≤ 1overt foot drop, 90 percent; pre–foot drop, 0 percent; p < 0.001). Pre–foot drop patients presented with a significantly higher preoperative pain visual analogue scale score (pre–foot drop, 6.2 ± 0.2; overt foot drop, 4.6 ± 0.3; p < 0.001) and normal electrodiagnostic studies (pre–foot drop, 31.4 percent; overt foot drop, 0.1 percent). Postoperatively, both groups of patients showed significant improvement in quality-of-life score (pre–foot drop, 2.6 ± 0.3; overt foot drop, 2.7 ± 0.3). Patients with obesity or a traumatic cause for common peroneal neuropathy were less likely to have improvements in quality of life after surgical decompression.
CONCLUSION:Increased recognition of common peroneal neuropathy can aid early management, relieve pain, and improve quality of life.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.
Determining functional recovery in adult patients with traumatic pan-brachial plexus injury (pBPI) is hampered by the fact that most outcome measures are collected in the clinical setting and may not ...reflect arm use in the real world. This study's objectives were to demonstrate the feasibility of using wearable motion sensor technology to quantify spontaneous arm movement in adult patients with pBPI after surgical reconstruction and report the time and intensity with which the affected arm was used.
Twenty-nine patients with pBPI who underwent surgical reconstruction at least 2 years prior were included in this study. Study participants wore an accelerometer on bilateral arms for 7 days. The vector time (VT) and magnitude with which each arm moved were collected and divided by the same values collected from the uninjured arm to generate a ratio (VT and vector magnitude VM, respectively) to quantify differences between the arms. Correlations between VT, VM, and patient demographic and physician-elicited clinical measures were calculated. Patients were enrolled at Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan, and data analysis was performed at the University of Michigan.
Twelve patients had pan-avulsion injuries, and 17 patients had C5 rupture with C6-T1 avulsion injuries. All underwent nerve reconstruction with contralateral C7 or ipsilateral C5 nerve roots as donors. At mean 7.3 years after surgery, the mean VT ratio was 0.54 ± 0.13 and the mean VM ratio was 0.30 ± 0.13. Both VT and VM ratios were significantly correlated with patient employment and movements at the elbow and forearm.
Wearable motion detection technology can capture spontaneous, real-world movements of the arm in patients who have undergone surgical reconstruction for pBPI. Despite severe injuries, these patients are able to use their affected arm 50% of the time and with 30% of the intensity of their unaffected arm, which is positively correlated with return to work after injury. These data support the use of surgical reconstruction for pBPI.
Abstract
Femoral nerve injuries are devastating injuries that lead to paralysis of the quadriceps muscles, weakening knee extension to prohibit ambulation. We report a devastating case of electrical ...injury-induced femoral neuropathy, where no apparent site of nerve disruption can be identified, thus inhibiting the traditional choices of nerve reconstruction such as nerve repair, grafting, or transfer. Concomitant spinal cord injury resulted in spastic myopathy of the antagonist muscles that further restricted knee extension. Our strategy was to perform (1) supercharge end-to-side technique (SETS) to augment the function of target muscles and (2) fractional tendon lengthening to release the spastic muscles. Dramatic postoperative improvement in passive and active range of motion highlights the effectiveness of this strategy to manage partial femoral nerve injuries.
To restore sensation after breast reconstruction, a modified surgical approach was employed by identifying the cut fourth intercostal lateral cutaneous branch, elongating it with intercostal nerve ...grafts, and coapting it to the innervating nerve of the flap or by using direct neurotization of the spared nipple/skin.
This was a retrospective case-control study including 56 patients who underwent breast neurotization surgery. Breast operations included immediate reconstruction after nipple-sparing mastectomy (36 patients), skin-sparing mastectomy (8 patients), and delayed reconstruction with nipple preservation (7 patients) or without nipple preservation (5 patients). Patients who underwent breast reconstruction without neurotization were included as the non-neurotization negative control group. The contralateral normal breasts were included as positive controls.
The mean(s.d.) monofilament test values were 0.07(0.10) g for the positive control breasts and 179.13(143.31) g for the breasts operated on in the non-neurotization group. Breasts that underwent neurotization had significantly better sensation after surgery, with a mean(s.d.) value of 35.61(92.63) g (P < 0.001). The mean(s.d.) sensory return after neurotization was gradual; 138.17(143.65) g in the first 6 months, 59.55(116.46) g at 7-12 months, 14.54(62.27) g at 13-18 months, and 0.37(0.50) g at 19-24 months after surgery. Two patients had accidental rupture of the pleura, which was repaired uneventfully. One patient underwent re-exploration due to a lack of improvement 1.5 years after neurotization.
Using the lateral cutaneous branch of the intercostal nerve as the innervating stump and elongating it with intercostal nerve grafts is a suitable technique to restore sensation after mastectomy. This method effectively innervates reconstructed breasts and spares the nipple/skin with minimal morbidity.
Synkinesis is a negative sequela of facial nerve recovery. Despite the need for effective treatment, controversy exists regarding optimal management and outcome reporting measures. The goals of this ...study were to evaluate the current synkinesis literature and compare the effectiveness of treatment modalities. A search of biomedical databases was performed in May 2019. Full-text English language articles of cohort studies or randomized controlled trials on synkinesis treatment were eligible for inclusion. Reviews, animal studies, and those without assessment of treatment effect were excluded. We found 592 unique citations; 33 articles were included in the final analyses. Nine studies focused on botulinum toxin (BTX-A), 7 on surgery, 5 on physical therapy (PT), and 12 on multimodal therapy. The Sunnybrook Facial Grading System was the most frequently used outcome measure (17 studies, 51.5%). All treatment modalities improved outcomes. Chemodenervation studies showed an average improvement of 17.8% (range 11–33.3%) in the respective outcome measures after treatment. PT improved by 29.7% (range 14.6–41.2%), surgery by 16.6% (range 4.7–41%), and combination therapy by 20.4% (range 5.13–37.5%). Only 21 studies (63.6%) provided data on adverse outcomes. There is lack of high-evidence level data for robust comparisons of postparetic synkinesis treatments; however, this condition is likely effectively treated nonsurgically and requires the support of a specialized multidisciplinary team. Adoption of standardized patient evaluation and outcome reporting methods is necessary for robust comparative effectiveness studies.
BACKGROUND:Surgical strategy to treat incomplete brachial plexus injury with palsies of the shoulder and elbow by using proximal nerve graft/transfer or distal nerve transfer is still debated. The ...aim of this study was to compare both strategies with respect to the recovery of elbow flexion.
METHODS:One hundred forty-seven patients were enrolled76 patients underwent reconstruction using proximal nerve graft/transfer, and 71 patients underwent reconstruction using distal nerve transfer. All patients were evaluated preoperatively and postoperatively to assess the recovery rate and muscle strength of elbow flexion. Shoulder abduction and hand grip power were also recorded to assess any concomitant postoperative changes between the two methods.
RESULTS:The best recovery rate for functional elbow flexion (p = 0.006) and the fastest recovery to M3 strength (p < 0.001) were found in the double fascicular transfer group. However, recovery of shoulder abduction with proximal nerve graft/transfer was significantly better than with distal nerve transfer (80.3 percent versus 66.2 percent in shoulder abduction ≥60 degrees; and 56.6 percent versus 38.0 percent in shoulder abduction ≥90 degrees). A significant decrease in grip strength between the operative and nonoperative hands was also found in patients undergoing distal nerve transfer (p = 0.001).
CONCLUSIONS:Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow function simultaneously. Distal nerve transfer can offer more efficient elbow flexion. Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
BACKGROUND:For the treatment of facial paralysis, functioning free muscle transplantation has become accepted standard treatment. Choice of donor nerve and number of surgery stages, however, are ...still matters of great debate.
METHODS:Between 2000 and 2011, 36 patients (out of 329; 11 percent) with 42 functioning free muscle transplantations were treated using spinal accessory nerve (XI)–innervated muscle for facial reanimation as a one-stage procedure. Indications included bilateral or unilateral Möbius syndrome, severe postparetic facial synkinesis, and patient preference. Postoperative smile training was required to achieve spontaneous smile. For outcome assessment, patients were evaluated using multidisciplinary methods, including objective smile excursion score (range, 0 to 4), cortical adaptation stage (range, I to V), tickle test, and subjective patient questionnaire and satisfaction score (range, 1 to 5).
RESULTS:Mean smile excursion score improved from 0.5 preoperatively to 3.4 postoperatively. Eighty-three percent of patients were able to perform independent and even spontaneous smile after 1 year of follow-up. Ninety percent of patients had a mean satisfaction score of 3.4 out of 5. However, 50 percent expressed more concern with aesthetic appearance than functional status. There was no functional morbidity of the donor shoulder in daily life.
CONCLUSIONS:The classic two-stage procedure is still the first choice for facial paralysis reconstruction. However, the effectiveness of XI-innervated free muscle for facial reanimation in a one-stage procedure has proven it to be a good alternative treatment. It has become second in popularity for facial paralysis reconstruction in the authors’ center.
CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
Over the course of the past two decades, improved outcomes following brachial plexus reconstruction have been attributed to newer nerve transfer techniques. However, key factors aside from surgical ...techniques have brought improved consistency to elbow flexion techniques in the latter decade.
One-hundred seventeen patients who underwent brachial plexus reconstruction from 1996 to 2006 were compared with 120 patients from 2007 to 2017. All patients were evaluated preoperatively and postoperatively to assess the recovery time and of elbow flexion strength.
In the first decade, nerve reconstruction methods included proximal nerve grafting, intercostal nerve transfer, and Oberlin-I transfer. In the second decade, newer methods such as double fascicular transfer and ipsilateral C7 division transfer to the anterior division of upper trunk were introduced. About 78.6% of the first decade group versus 87.5% of the second decade group were able to reach M3 flexion strength (
= 0.04), with shorter time recovery to reach M3 in the 2nd decade. About 59.8% of the first decade group versus 65.0% of the second decade group were able to reach M4 (
= 0.28), but no significant difference in time of recovery. In both groups, the double fascicular nerve transfer had the highest impact when introduced in the second decade. More precise magnetic resonance imaging (MRI) techniques helped to diagnose the level of injury, the roots involved and evaluate the health of the donor nerves in preparation for intraplexus transfer.
In addition to modified techniques in nerve transfers, (1) MRI-assisted evaluation and surgical exploration of the roots with (2) more judicious choice of donor nerves for primary nerve transfer were factors that ensured reliable and outcomes in the second decade.
The restoration of finger movement in total brachial plexus injuries (BPIs) is an ultimate challenge. Pedicled vascularized ulnar nerve graft (VUNG) connecting a proximal root to distal target nerves ...has shown unpredictable outcomes. We modified this technique by harvesting VUNG as a free flap to reinnervate median nerve (MN). We analyzed the long-term outcomes of these methods.
From years 1998 to 2015, 118 acute total brachial plexus patients received free VUNG to innervate the MN. Patients were followed up at least 5 years after the initial surgery. Donor nerves included the ipsilateral C5 root (25 patients) or contralateral C7 root (CC7 = 93 patients). Recovery of finger and elbow flexion was evaluated with the modified Medical Research Council system. Michigan Hand Score and Quick-DASH were used to represent the patient-reported outcomes.
For finger flexion, ipsilateral C5 transfer to MN alone yielded similar outcomes to MN + MCN (musculocutaneous nerve), while CC7 had significantly better finger flexion when coapted to MN alone than to MN + MCN. Approximately 75% patients were able to achieve finger flexion with nerve transfer alone. For elbow flexion, best outcome was seen in the ipsilateral C5 to MCN and MN.
In acute total BPI, the priority is to identify the ipsilateral C5 root to innervate MN, with concomitant innervation of MCN to establish the best outcomes for finger and elbow flexion. CC7 is more reliable when used to innervate one target (MN).
III.
BACKGROUND:Functioning free muscle transplantation (FFMT) is currently the gold standard for the reconstruction of facial paralysis, focusing more on the upper lip reconstruction rather than the ...lower lip. This study aimed to compare different lower lip reconstructive methods when performing FFMT for facial reanimation.
MATERIALS AND METHODS:Retrospective review of FFMT for facial reanimation from 2007 to 2015 was performed. Patients were divided into three groupsGroup 1 (n=15), a free plantaris tendon graft anchored to the gracilis muscle was passed into the lower lip to create a loop within; Group 2 (n=12), an aponeurosis tail of the gracilis muscle was attached to the lower lip; Group 3 (n=18), no suspension of lower lip was performed. All patients had at least two years of follow-up. Outcomes were assessed by photos and videos, including subjective evaluation of midline deviation and horizontal tilt and objective analysis of smile dimensions and area.
RESULTS:A total of 45 patients were included. Results from the subjective evaluation demonstrate group 1 patients having the best improvement (overall scorep=0.004 & 0.005, Fisher’s exact test). The objective evaluation showed group 1 and 2 patients with better results compared to group 3 (Horizontal component p=0.009, vertical component p=0.004, and area distribution p<0.001, Kruskall-Wallis test).
CONCLUSION:Both plantaris tendon graft and gracilis aponeurosis achieved better improvement in subjective and objective evaluations than those who had no reconstruction of the lower lip. In particular, the plantaris tendon graft can achieve the most lower lip excursion with overall improved symmetry.
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