Preoperative Sensation Research Articles

Change in lower limb length following total knee arthroplasty

BackgroundLength variations of the lower limbs after total knee arthroplasty (TKA) constitute a poorly evaluated parameter and can be associated with worse functional outcomes. The objectives of this study were to: 1) describe the variations in the lower limb length after TKA according to the digital accuracy of the computerized navigation system used for prosthesis implantation, 2) describe patient sensation of limb length modification at 3 months postoperatively and to identify its risk factors, 3) identify factors affecting lower limb length modification and to analyze the predictive value causing in the patient the sensation of lower limb discrepancy. HypothesisWe hypothesize that there may be a lower limb length discrepancy after TKA, which may cause some distress to the patient. Patients and methodsThis prospective study included 100 TKAs implanted with navigation gap-balanced adjusted mechanical alignment. Were compared the length of the lower limb before and after implantation and the patient’s changes in leg length perception at 3 months postoperatively. A subgroup analysis was performed according to preoperative knee deformities: varus knee was an HKA < 177 °, normal knee was an HKA between 117°-183 ° and valgus was an HKA >183 °. ResultsNinety-seven out of 100 patients experienced lengthening compared to the preoperative ipsilateral length, and twenty-three experienced lengthening greater than 10 mm. The mean lengthening was 7.3 mm (maximum 24.8 mm). Lengthening was significantly greater in valgus knees 9.9 mm [range, 2.0-24.8] than in varus 7.2 mm [range, 1.46-19.4] and normal knees 4.11 mm [range, 0.4-11.4] (p < 0.05). The correction of frontal and sagittal deformation were risk factors for limb length modification (OR = 0.595; 95% CI (0.544-0.816) (p = 0.001), OR = 0.396; 95% CI (0.351-0.653) (p = 0.001)).Twenty-two patients reported a sensation of limb length change: 11 (50%) reported equalization, whereas the remainder reported lengthening with a leg length difference. The preoperative sensation of lower limb length inequality was the unique factor affecting the patient’s perception post-surgery (OR = 37.50; 95% CI (9.730-144.526) (p = 0.0001)). A threshold value of 6.6 mm was identified for the sensation of limb length modification. ConclusionNavigation is a tool for describing ipsilateral leg length variations after TKA. These variations are significant and perhaps explain some patient dissatisfaction. A partial correction of the frontal deformity according to the knee phenotype could limit the risk of modification of the native length. Level of evidenceIV; Descriptive therapeutic prospective study.

Prospective Sensory Outcomes for Targeted Nipple Areola Complex Reinnervation (TNR) in Gender-Affirming Double Incision Mastectomy with Free Nipple Grafting.

This study analyses the anatomy and sensory outcomes of targeted nipple areola complex reinnervation (TNR) in gender-affirming double incision mastectomy with free nipple grafting (FNG). TNR is a novel technique to preserve and reconstruct intercostal nerves (ICN) to improve postoperative sensation. There is little evidence on relevant anatomy and outcomes. 25 patients were prospectively enrolled. Data included demographics, surgical technique, and axon/fascicle counts. Quantitative sensory evaluation using monofilaments and qualitative patient reported questionnaires were completed preoperatively, and at one, three, six, nine and twelve months postoperatively. 50 mastectomies were performed. Per mastectomy, the median number of ICN found and used was 2 (1-5). Axon and fascicle counts were not significantly different between ICN branches ( P >0.05). BMI ≥30kg/m 2 and mastectomy weight ≥800g were associated with significantly worse preoperative sensation ( P <0.05). Compared to preoperative values, NAC sensation was worse at 1 month ( P <0.01), comparable at 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. Chest sensation was comparable to the preoperative measurements at 1 and 3 months ( P >0.05), and significantly better at 12 months ( P <0.05) postoperatively. NAC sensation was significantly better when direct coaptation was performed compared to use of allograft only ( P <0.05), and with direct coaptation of ≥2 branches compared to direct coaptation of a single branch ( P <0.05). All patients reported return of nipple and chest sensation at one year postoperatively and 88% reported return of some degree of erogenous sensation. TNR allows for restoration of NAC and chest sensation within 3 months postoperatively. Use of multiple ICN branches and direct coaptation led to the best sensory outcomes.

Replacing an Implant-Based with a DIEP Flap Breast Reconstruction: Breast Sensation and Quality of Life.

In this cohort study, the authors compared breast sensation and quality of life (QoL) after replacement of an implant-based breast reconstruction with a deep inferior epigastric perforator (DIEP) flap reconstruction in a singular sample of women. Women with implant-based breast reconstruction before their DIEP flap were included. Women formed their own control. Breast sensation was measured using Semmes-Weinstein monofilaments. QoL was evaluated using BREAST-Q questionnaires. Preoperative (T0) sensation and QoL were compared with postoperative values at 6 months (T1), at 12 months (T2), and at maximum follow-up (Tmax, sensation only). A linear mixed effects regression was used for Semmes-Weinstein monofilaments measurements; a paired samples t test was used for BREAST-Q scores. Most women chose replacement of their implant by a DIEP flap because of implant-related complaints. Postoperative sensation decreased significantly compared with preoperative sensation after T1 (mean, 5.1 months), T2 (mean, 14.6 months), and Tmax (mean, 17.6 months) for the total breast but recovers to preoperative levels for the native skin after an average of 1.5 years. Nerve coaptation positively influenced recovery of sensation. BREAST-Q scores increased significantly after 6 and 12 months over the domains Satisfaction with Breasts, Psychosocial Well-Being, Physical Well-Being of the Chest, and Sexual Well-Being. Scores decreased significantly in Physical Well-Being of the Abdomen after 6 months. Replacing an implant with a DIEP flap initially causes a decrease in overall breast sensation, gradually recovering to preoperative levels for native skin, and can significantly increase QoL with the right indication. Superior recovery of sensation and QoL may be obtained by accompanying the DIEP flap with nerve coaptation. Therapeutic, IV.

Tactile Hand Sensation Following Split Thickness Radial Forearm Free Flap Phalloplasty

PURPOSE: Radial forearm free flap (RFFF) phalloplasty is often referred to as the gold standard for gender-affirming phalloplasty procedures.1 Forearm neuropathy, a frequently listed complication of RFFF phalloplasty, has yet to be quantified in patients who undergo this procedure with a device as precise as the Pressure Specified Sensory Device (PSSD). The purpose of this study was to determine whether there is a change in tactile hand sensation following RFFF phalloplasty, and whether these changes vary by cutaneous region of the hand. The results of this study will help counsel patients who may view potential neuropathy as a barrier to pursuing this procedure. METHODS: A total of 9 patients undergoing split thickness RFFF phalloplasty were tested preoperatively and 1-week postoperatively for tactile hand sensation. Testing was conducted using a 2-point static (2 PS) test with a Disk-Criminator and PSSD. The testing sites included the cutaneous regions of the dorsal first webspace and the first phalanx of the index finger and pollex of the RFFF donor arm. The 2 PSSD prongs were set at a distance determined by initial testing with the Disk-Criminator. The PSSD measured the threshold of pressure necessary for the patient to discriminate 2 points. Two-sided paired t tests compared the pre- and postoperative pressure values on each of the 3 hand locations. The numerical differences in pre- and postoperative pressures were then compared between each of the 3 locations to determine whether or not there was a difference in postoperative sensation based on hand region. The PSSD pressure values were standardized based on the prong distance determined by the Disk-Criminator, and percent change in standardized PSSD score differences for each cutaneous region was calculated. All tests were considered significant at P < 0.05. RESULTS: There were no significant differences between pre- and postoperative PSSD pressures for all cutaneous regions tested (P > 0.05). However, on average, patients required 8.04% more pressure applied in the dorsal first webspace in order to discriminate 2 points, 8.43% more in the first phalanx of the index finger, and 16.7% more in the first phalanx of the pollex postphalloplasty (all n.s.). Furthermore, when comparing each of the three cutaneous regions to each other, there was no difference in the change in pressures between each region (P > 0.05). In other words, each of the three regions of the hand was similarly impacted by the operation. CONCLUSIONS: The results of this study suggest that while past literature reports cases of numbness and/or tingling post-RFFF phalloplasty,1 immediate postoperative sensation is not significantly different than preoperative sensation. The fear of donor arm neuropathy is a potential barrier for patients seeking this life-changing procedure, yet this study quantifies the degree of neuronal damage and may encourage patients to undergo the procedure. These results will help guide patient-physician conversations regarding RFFF phalloplasty in order to create realistic patient expectations for postoperative outcomes. REFERENCE: 1. Kovar A, Choi S, Iorio ML. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg Glob Open. 2019;7:e2442.

Factors influencing the outcome of surgery for pelvic organ prolapse

Introduction and hypothesisPelvic organ prolapse (POP) surgery is a common gynecological procedure. Our aim was to assess the influence of obesity and other risk factors on the outcome of anterior and posterior colporrhaphy with and without mesh.MethodsData were retrieved from the Swedish National Register for Gynecological Surgery on 18,554 women undergoing primary and repeat POP surgery without concomitant urinary incontinence (UI) surgery between 2006 and 2015. Multivariate logistic regression analyses were used to identify independent risk factors for a sensation of a vaginal bulge, de novo UI, and residual UI 1 year after surgery.ResultsThe overall subjective cure rate 1 year after surgery was 80% (with mesh 86.4% vs 77.3% without mesh, p < 0.001). The complication rate was low, but was more frequent in repeat surgery that were mainly mesh related. The use of mesh was also associated with more frequent de novo UI, but patient satisfaction and cure rates were higher compared with surgery without mesh. Preoperative sensation of a vaginal bulge, severe postoperative complications, anterior colporrhaphy, prior hysterectomy, postoperative infections, local anesthesia, and body mass index (BMI) ≥30 were risk factors for sensation of a vaginal bulge 1 year postsurgery. Obesity had no effect on complication rates but was associated increased urinary incontinence (UI) after primary surgery. Obesity had no influence on cure or voiding status in women undergoing repeat surgery.ConclusionsObesity had an impact on the sensation of a vaginal bulge and the presence of UI after primary surgery but not on complications.

Risk Factors Affecting Somatosensory Function After Sagittal Split Osteotomy

The aim of this study was to evaluate potential individual and intraoperative risk factors associated with bilateral sagittal split osteotomy (BSSO) and to correlate the findings with postoperative changes in somatosensory function. A total of 18 men and 29 women (mean age, 31 +/- 10 years) scheduled for BSSO participated in 1 session before BSSO and 5 sessions after BSSO (at 2 and 14 days and 3, 6, and 12 months). At each session, subjective oral sensation was scored and quantitative sensory tests were performed. The results showed that complete exposure and free dissection of the inferior alveolar nerve during BSSO increased self-reported changes in lower lip sensation and lower lip tactile threshold after BSSO (P < .01). Long surgical movements reduced self-perceived jaw-opening function and impaired 2-point discrimination (P < .05). Significant correlations were noted between preoperative values for somatosensory function and changes in these variables after BSSO. Patients with low sensory thresholds before BSSO experienced more impairment than those patients with higher preoperative sensory thresholds. These findings imply that somatosensory function after BSSO is dependent on both intraoperative risk factors and preoperative sensation levels.

Sensibility following Innervated Free TRAM Flap for Breast Reconstruction

The free transverse rectus abdominis musculocutaneous (TRAM) flap has proven to be a reliable means of recreating the aesthetic breast form after mastectomy. The purpose of this study was to determine whether neurotization of the free TRAM flap improved sensation of the reconstructed breast. Twenty-seven patients undergoing 37 free TRAM flap reconstructions were randomized to receive either an innervated (12 patients, 18 breasts) or a noninnervated flap (15 patients, 19 breasts). A nerve repair between the T10 intercostal of the TRAM flap and the anterior sensory branch of the fourth intercostal nerve was performed for innervation. Sensory testing (Semmes-Weinstein monofilaments, hot-cold discrimination, two-point discrimination) was performed by one blinded examiner in a standardized pattern. Mean follow-up was 16 months. Demographic analysis revealed no significant differences in patient age, height, smoking, radiation therapy, and nipple-areola reconstruction between patient groups (p > 0.3). Patients in the noninnervated group, however, were heavier (p = 0.03). Preoperative sensation was not significantly different in the noninnervated and innervated groups. Postoperative pressure threshold and temperature discrimination were significantly improved in the innervated flaps (p < 0.05). Noninnervated flaps displayed a pattern of increasing sensibility from the center toward the periphery while innervated flaps regained sensation throughout. Innervation of the free TRAM flap provides improved sensation to the reconstructed breast and is a simple adjunct to breast reconstruction.

Nerve Growth Factor Concentration and Implications in Photorefractive Keratectomy vs Laser In Situ Keratomileusis

To determine whether tear nerve growth factor (NGF) concentration correlates with corneal sensation and ocular surface dryness after photorefractive keratectomy (PRK) and laser in situ keratomileusis (LASIK). Prospective, nonrandomized comparative clinical trial. Seventy eyes of 35 patients and 76 eyes of 38 patients underwent PRK and LASIK procedures to correct myopia and myopic astigmatism, respectively. Total tear protein level, tear NGF concentration, tear film breakup time (BUT) and Schirmer values were measured before and 1 day, 1 week, 1 month, 3 months, and 6 months after surgery. The postoperative mean tear NGF/total tear protein (NGF/tP) ratio increased in both PRK and LASIK patients compared with preoperative levels (P < .0001). At 1 week and 1 month postoperatively, the NGF/tP ratio was higher in PRK than in LASIK subjects (P < .0001). Before 6 months postoperatively, the mean corneal sensation after LASIK in the ablated zone was lower than the preoperative sensation (P < .0001), but this was not the case in PRK subjects. Mean BUT and Schirmer values were significantly lower in LASIK-treated eyes compared with PRK-treated eyes up to 6 months postoperatively (P < .0001). The early postoperative tear NGF/tP ratio correlated with the postoperative 6-month value of corneal sensation, BUT, and Schirmer values. The difference in the postoperative corneal sensation and ocular surface dryness between PRK-treated and LASIK-treated eyes might be related to the difference in the early postoperative levels of NGF, which is a potent nerve growth stimulator.

Sensory nerve disturbance following le fort i osteotomy

This study assessed sensory nerve disturbance after Le Fort I osteotomy using the electric pulp test, pin-prick sensation, fine touch, and cold sensation. After 6 months, 78% of teeth positive preoperatively to an electric pulp tester regained sensitivity. Return of palatal sensation was affected by whether or not the greater palatine nerve (GPN) was divided during surgery. After 6 months, where the GPN was intact, all patients had fine touch sensation (88% at the preoperative level), and all had pin-prick sensation (97% at preoperative level). When the GPN was divided, all patients had fine touch sensation (13% at preoperative level), and all had pin-prick sensation (63% at preoperative level). The differences in the return to preoperative sensation were significant for fine touch ( P=0.0001) and for pin-prick ( P=0.03) by chi-square analysis. Sensation returned more quickly and more completely in the two cases where the contralateral GPN was intact. In the buccal mucosa, 95% of patients regained some fine touch sensation after 6 months, but none returned to the preoperative level. Similarly, 85% regained some pin-prick sensation, but none achieved preoperative levels. Cold sensation, pin-prick sensation, and fine touch on the face returned to the preoperative level in all patients by 6 weeks postoperatively.

Recovery of neurosensory function following orthognathic surgery

The purpose of this study was to prospectively define the recovery of touch discrimination following four commonly performed surgical procedures in 22 consecutive patients with no previous maxillofacial surgery. The surgical groups studied were Le Fort I osteotomy (LEFORT; n = 13), sagittal split ramus osteotomy (SSRO; n = 6), intraoral vertical ramus osteotomy (IVRO; n = 9), and isolated genioplasty (GENIO; n = 5). Neurosensory function was assessed by three different testing modalities which included static light touch (SLT), moving touch discrimination (MTD), and two-point discrimination (TPD). Cutaneous sensation of the lower lip and chin were examined for the mandibular procedures, whereas the infraorbital and upper lip regions were evaluated following maxillary surgery. Immediately following surgery, each group varied in both the incidence and magnitude of neurosensory deficits (NSD). The SSRO group had the highest percentage of sites with immediate postsurgical NSD to both SLT (72%) and MTD (67%), followed by the LEFORT (SLT = 50%, MDT = 58%), GENIO (SLT = 27%, MTD = 6%), and IVRO groups (SLT = 11%, MTD = 18%), respectively. Each group also varied in the severity of the initial postoperative deficit as measured by SLT, with the SSRO group showing the greatest deficit followed by the LEFORT, GENIO, and IVRO groups. During the 6-month recovery period each group approached preoperative levels of sensation at a different rate. The LEFORT group recovered most rapidly, with few anatomic sites showing NSD (SLT = 20%, MTD = 5%) at the 1-month postoperative examination, and the majority of the group (96%) returned to preoperative sensation by 3 months following surgery. The SSRO group recovered more slowly, with approximately half of the group demonstrating a deficit (SLT = 50%, MTD = 59%) at 1 month, which diminished to about one fourth of the sites (SLT = 25%, MTD = 5%) by 3 months. Most of the SSRO group (90%) exhibited no residual deficit 6 months following surgery. The IVRO group had few sites with immediate NSD (SLT = 11%, MTD = 15%). In none of the surgical groups was a statistically significant correlation found between the severity of the initial NSD and length of time to complete recovery.