Abstract
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.
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.
Nerve entrapment: update Tang, David T; Barbour, John R; Davidge, Kristen M ...
Plastic and reconstructive surgery (1963)
135, Številka:
1
Journal Article
Recenzirano
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.
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.
Objective The mechanisms contributing to ascending thoracic aortic aneurysms associated with bicuspid aortic valves may differ from ascending thoracic aortic aneurysms with tricuspid aortic valves. ...Matrix metalloproteinases and their endogenous inhibitors have been causally linked to ascending thoracic aortic aneurysm formation. This study tested the hypothesis that specific and different matrix metalloproteinase and tissue inhibitors of metalloproteinase profiles would be observed in ascending thoracic aortic aneurysm samples from patients with bicuspid aortic valves versus tricuspid aortic valves. Methods Ascending thoracic aortic aneurysm samples taken from patients with bicuspid aortic valve (n = 53) and patients with tricuspid aortic valve (n = 46) were assessed for representative subtypes of all matrix metalloproteinase classes and all 4 known tissue inhibitors of metalloproteinases. Levels were compared optical density units, median (interquartile range) both to reference control ascending aortic samples (n = 26) and within each valve group by aneurysm diameter (≤3.9 cm, 4.0-5.9 cm and ≥6.0 cm). Results Different and specific matrix metalloproteinase and tissue inhibitors of metalloproteinase profiles were observed in the ascending thoracic aortic aneurysm groups. In bicuspid aortic valves, matrix metalloproteinase-2 increased by 34% when compared with either tricuspid aortic valves or control ( P < .05), and matrix metalloproteinase-14 decreased by 59% compared with tricuspid aortic valves ( P < .05). In tricuspid aortic valve samples, tissue inhibitors of metalloproteinase-2 decreased by 35% when compared with either tricuspid aortic valves or control ( P < .05), and matrix metalloproteinase-13 increased by 140% in the 4.0- to 5.9-cm diameter range ( P < .05). Conclusions A unique matrix metalloproteinase and tissue inhibitor of metalloproteinase portfolio was observed in ascending thoracic aortic aneurysms from patients with bicuspid aortic valve compared with patients with tricuspid aortic valve. These differences, suggesting disparate mechanisms of extracellular matrix remodeling, may provide unique biochemical targets for ascending thoracic aortic aneurysm prognostication and treatment in these 2 groups of patients.
Thoracic aortic aneurysms (TAAs) are a rare but potentially devastating condition. Current surgical treatment of TAAs usually involves a major operation, which conveys many risks to the patient. ...Better knowledge of the cellular events that lead to aneurysm formation may elucidate less morbid treatment options for this condition. A number of recent studies have identified that the relative abundance and activity of extracellular matrix (ECM) proteolytic systems are increased with TAAs. Specifically, the matrix metalloproteinases (MMPs) have been linked through numerous studies to TAA formation. MMPs comprise a family of ECM-degrading proteinases. Endogenous tissue inhibitors (TIMPs) normally regulate MMP activity, and the activation of MMPs is complex and tightly controlled. Aneurysm formation may be related to relative changes in the balance between MMP/TIMP abundance favoring proteolysis. Through ECM degradation, the medial layer will undergo structural remodeling and a loss of structural integrity, leading to TAA formation. The goals of this review are to examine the structure of the normal and aneurysmal thoracic aorta and to place the new findings regarding ECM proteolysis in perspective with regard to TAA formation and progression. Through an integration of basic and clinical studies regarding the underlying molecular basis for proteolysis of the thoracic aorta, improved diagnostic, prognostic, and therapeutic strategies for this disease process are likely to be realized.
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.
The present study tested the hypothesis that changes in the resident endogenous cellular population accompany alterations in aortic collagen and elastin content during thoracic aortic aneurysm (TAA) ...development in a murine model. Descending thoracic aortas were analyzed at various time points (2, 4, 8, and 16 weeks) post-TAA induction (0.5 M CaCl2, 15 minutes). Aortic tissue sections were subjected to histological staining and morphometric analysis for collagen and elastin, as well as immunostaining for cell-type-specific markers to quantify fibroblasts, myofibroblasts, and smooth-muscle cells. Results were compared with reference control mice processed in the same fashion. Aortic dilatation was accompanied by changes in the elastic architecture that included: a decreased number of elastic lamellae (from 6 to 4); altered area fraction of elastin (elevated at 4 weeks and decreased at 16 weeks); and a decreased area between elastic lamellae (minimum reached at 4 weeks). Total collagen content did not change over time. Increased immunoreactivity for fibroblast and myofibroblast markers was observed at 8- and 16-week post-TAA-induction, whereas immunoreactivity for smooth-muscle cell markers peaked at 4 weeks and returned to baseline by 16 weeks. Therefore, this study demonstrated that changes in aortic elastin content were accompanied by the emergence of a subset of fibroblast-derived myofibroblasts whose altered phenotype may play a significant role in TAA development through the enhancement of extracellular matrix proteolysis.
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.
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.
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.
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.
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.
Therapeutic, V.
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.
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.
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.
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.
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