Sensory Recovery Research Articles

Defects of the sciatic nerve and its divisions treated by direct suturing in 90 degrees knee flexion: report on the first clinical series.

To evaluate functional results after treatment of large defects of the sciatic nerve and its divisions by direct nerve suturing in high knee flexion. A retrospective review was conducted in patients treated for lower extremity nerve defects between 2011 and 2019. Inclusion criteria were a defect > 2cm with a minimal follow-up period of 2years for the sciatic nerve and 1year for its divisions. Nerve defects were bridged by an end-to-end suture with the knee flexed at 90° for 6weeks. Functional results were assessed based on the Medical Research Council's grading system. Seventeen patients with a mean age of 27.6years were included. They presented with seven sciatic nerve defects and ten division defects, including eight missile injuries. The mean time to surgery was 12.3weeks and the mean nerve defect length was 5cm. Overall, 21 nerve sutures were performed, with eight in the tibial distribution and 13 in the fibular distribution. Post-operatively, there was no significant knee stiffness related to the immobilization. The mean follow-up time was 24.5months. Meaningful motor and sensory recovery were observed after 7 of 8 sutures in the tibial distribution and 11 of 13 sutures in the fibular distribution. A functional sural triceps muscle with protective sensibility of the sole was restored in all patients. There were no differences according to the injury mechanisms. Temporary knee flexion at 90° allows for direct coaptation of sciatic nerve defects up to 8cm, with promising results no matter the level or mechanism of injury.

Repair of finger pulp defects using a free second toe pulp flap anastomosed with the palmar vein

PurposeTo evaluate the clinical utility of surgical reconstruction of finger pulp defects using a plantar flap derived from the toes, with vascular anastomosis of the toe-finger artery and the plantar-palmar vein of the finger.MethodsBetween April 2018 and November 2020, 29 patients with finger pulp defects underwent treatment via the transplantation of pulp tissue from the second toe, with the plantar vein of the toe and the palmar vein of the finger being anastomosed during this procedure. In addition, an anastomosis of the toe and finger artery and nerve was conducted, with a flap size of 1.0 cm * 0.8 cm–2.3 cm * 4.0 cm being used for such repair. Donor tissue sites were closed without introducing deformities or other complications.ResultsIn all patients in the present study, flap tissues survived and did not exhibit evidence of vascular crisis over a mean 16.8-month follow-up period (range 8–24 months). After successful skin flap grafting, they exhibited good elasticity and a soft texture. At three months post-surgery, some patients reported partial recovery of touch sensation in the transplanted tissue, while pain recovery was evident in some patients at 4–6 months post-surgery. No deformities or other complications were observed at the donor site, and the ability of patients to walk normally was not impaired.ConclusionThe anastomosis of toe plantar flaps with the palmar vein can facilitate the repair of finger pulp injuries without the need to dissect the dorsal vein of the toe, allowing for the suturing of donor tissue sites without causing any deformities or other complications. This surgical approach can easily be conducted with satisfactory clinical outcomes.

Emergency Foot Fillet Free Flap Based on Posterior Tibial Vessels for Reconstruction of Contralateral Heel and Sole: A Unique Spare Part Surgery

IntroductionReconstruction of the sole is an extremely challenging problem for a reconstructive microsurgeon. The specialized nature of its skin and subcutaneous tissue makes reconstruction arduous. When posed with complex bilateral lower extremity trauma where one limb was nonsalvageable, we harvested the uninjured foot fillet flap for free flap cover to reconstruct the contralateral sole. We report two such cases with follow-up assessment. Patients and MethodsTwo cases of sole reconstruction with emergency foot fillet free flap scavenged from the amputated contralateral limb were retrospectively analyzed. In both the patients, foot fillet free flap based on the posterior tibial neurovascular bundle was used. The follow-up assessment data collected included flap status, presence of any complications and prosthesis use, and functional status of the limbs at final follow-up. ResultsBoth the free flaps survived. Postoperative period was uneventful. No complications such as wound infection, delayed healing, flap necrosis, or scar breakdown were noted. The plantar flaps had recovery of protective sensation. Both the patients are ambulant; the first man with a fitted prosthesis and the second woman with the aid of a walker. ConclusionThe opportunity to utilize spare tissue from the amputated limb should be seized. Loss of the plantar aspect of foot poses a real challenge. The plantar foot fillet free flap is a durable flap with preservation of plantar sensations. It is probably the best choice as it replaces “like with like.” Prerequisites for utilizing the “spare part surgery” concept are meticulous initial debridement as well as emergency free tissue transfer, which require senior input and excellent infrastructure.

Adenosine and Astrocytes Determine the Developmental Dynamics of Spike Timing-Dependent Plasticity in the Somatosensory Cortex.

During development, critical periods of synaptic plasticity facilitate the reordering and refinement of neural connections, allowing the definitive synaptic circuits responsible for correct adult physiology to be established. The L4-L2/3 synapses in the somatosensory cortex (S1) exhibit a presynaptic form of spike timing-dependent long-term depression (t-LTD) that probably fulfills a role in synaptic refinement. This t-LTD persists until the fourth postnatal week in mice, disappearing thereafter. When we investigated the mechanisms underlying this maturation-related loss of t-LTD in either sex mouse slices, we found that it could be completely recovered by antagonizing adenosine type 1 receptors. By contrast, an agonist of A1R impeded the induction of t-LTD at P13-27. Furthermore, we found that the adenosine that mediated the loss of t-LTD at the end of the fourth week of development is most probably supplied by astrocytes. At more mature stages (P38-60), we found that the protocol used to induce t-LTD provokes t-LTP. We characterized the mechanisms underlying the induction of this form of LTP, and we found it to be expressed presynaptically, as witnessed by paired-pulse and coefficient of variation analysis. In addition, this form of presynaptic t-LTP requires the activation of NMDARs and mGlu1Rs, and the entry of Ca2+ into the postsynaptic neuron through L-type voltage-dependent Ca2+ channels. Nitric oxide is also required for t-LTP as a messenger in the postsynaptic neuron as are the adenosine and glutamate that are released in association with astrocyte signaling. These results provide direct evidence of the mechanisms that close the window of plasticity associated with t-LTD and that drive the switch in synaptic transmission from t-LTD to t-LTP at L4-L2/3 synapses, in which astrocytes play a central role.SIGNIFICANCE STATEMENT During development, critical periods of plasticity facilitate the reordering and refining of neural connections, allowing correct adult physiology to be established. The L4-L2/3 synapses in the somatosensory cortex exhibit a presynaptic form plasticity (LTD) that probably fulfills a role in synaptic refinement. It is present until the fourth postnatal week in mice, disappearing thereafter. The mechanisms that are responsible for this loss of plasticity are not clear. We describe here these mechanisms and those involved in the switch from LTD to LTP observed as the brain matures. Defining these events responsible for closing (and opening) plasticity windows may be important for brain repair, sensorial recovery, the treatment of neurodevelopmental disorders, and for educational policy.

Effects of Intensive Vibratory Treatment with a Robotic System on the Recovery of Sensation and Function in Patients with Subacute and Chronic Stroke: A Non-Randomized Clinical Trial.

Background: Sensory–motor deficits are frequent and affect the functionality after stroke. The use of robotic systems to improve functionality and motor performance is advisable; therefore, the aim of the present study was to evaluate the effects of intensive, high-frequency vibration treatment administered with a robotic system in subacute and chronic stroke patients in terms of upper limb sensitivity, motor function, quantity and quality of movement, and quality of life. Methods: A simple-blind, non-randomized controlled trial was conducted. The control group received conventional rehabilitation treatment and the experimental group received robotic treatment with an Amadeo® robot in addition to their conventional rehabilitation sessions. Results: Intragroup analysis identified significant improvements in the experimental group in hand (p = 0.012), arm (p = 0.018), and shoulder (p = 0.027) sensitivity, as well as in motor function (FMA-UEmotor function, p = 0.028), integration of the affected limb (MAL-14amount scale, p = 0.011; MAL-14How well scale, p = 0.008), and perceived quality of life (SIS-16, p = 0.008). The measures between the control and experimental groups showed statistically significant differences in motor performance and spontaneous use of the affected limb (MAL-14amount scale, p = 0.021; MAL-14How well scale, p = 0.037). Conclusions: Intensive, high-frequency vibration with a robotic system, in combination with conventional intervention, improves the recovery of upper limb function in terms of quantity and quality of movement in patients with subacute and chronic stroke.

Modified Mini-Keystone Flaps for Coverage of Tiny Volar Pulp Defects of the Fingertips in Cases with Missing Amputation Skin Stumps: A Retrospective Study.

This study aimed to demonstrate the expanding versatility of keystone flap reconstruction in fingertips. Fifteen patients who underwent the modified mini-keystone flap reconstruction for tiny volar pulp defects of the fingertip between September 2020 and February 2021 were included in this study (average age: 43.4 ± 13.52 years, range: 19–61 years). Patient data were retrospectively collected from their medical records. The two-point discrimination test was used to evaluate the degree of sensory recovery. All defects were successfully covered with the modified mini-keystone flap. The defect sizes ranged from 0.5 cm × 1 cm to 1.2 cm × 2.0 cm, and the flap sizes ranged from 0.7 cm × 1.5 cm to 1.5 cm × 3.0 cm. Although one patient showed a small distal margin maceration, all flaps survived fully. The overall outcomes were favorable at the mean follow-up period of 5.73 ± 0.79 months. We suggest that the modified mini-keystone flap technique is a promising alternative modality for covering tiny volar pulp defects of the fingertip, with few complications and favorable outcomes.

Effects of Olfactory Mucosa Stem/Stromal Cell and Olfactory Ensheating Cells Secretome on Peripheral Nerve Regeneration.

Cell secretome has been explored as a cell-free technique with high scientific and medical interest for Regenerative Medicine. In this work, the secretome produced and collected from Olfactory Mucosa Mesenchymal Stem Cells and Olfactory Ensheating Cells was analyzed and therapeutically applied to promote peripheral nerve regeneration. The analysis of the conditioned medium revealed the production and secretion of several factors with immunomodulatory functions, capable of intervening beneficially in the phases of nerve regeneration. Subsequently, the conditioned medium was applied to sciatic nerves of rats after neurotmesis, using Reaxon® as tube-guides. Over 20 weeks, the animals were subjected to periodic functional assessments, and after this period, the sciatic nerves and cranial tibial muscles were evaluated stereologically and histomorphometrically, respectively. The results obtained allowed to confirm the beneficial effects resulting from the application of this therapeutic combination. The administration of conditioned medium from Olfactory Mucosal Mesenchymal Stem Cells led to the best results in motor performance, sensory recovery, and gait patterns. Stereological and histomorphometric evaluation also revealed the ability of this therapeutic combination to promote nervous and muscular histologic reorganization during the regenerative process. The therapeutic combination discussed in this work shows promising results and should be further explored to clarify irregularities found in the outcomes and to allow establishing the use of cell secretome as a new therapeutic field applied in the treatment of peripheral nerves after injury.

Tactile Sensation Improves Following Motor Rehabilitation for Chronic Stroke: The VIGoROUS Randomized Controlled Trial

Background. Up to 85% of people with chronic stroke experience somatosensory impairment, which contributes to poor sensorimotor control and non-use of the affected limb. Neurophysiological mechanisms suggest motor rehabilitation may improve tactile sense post-stroke, however, somatosensory recovery has rarely been reported in controlled trials. Objective. To compare the effect of four upper limb motor rehabilitation programs on the recovery of tactile sensation in adults with chronic stroke. Methods. Adults with chronic stroke and mild or moderate upper extremity hemiparesis (n = 167) were enrolled in a multi-site randomized controlled trial. Participants completed three weeks of gaming therapy, gaming therapy with additional telerehabilition, Constraint-Induced Movement therapy, or traditional rehabilitation. Here, we report the results of a secondary outcome, tactile sensation, measured with monofilaments, before and after treatment, and 6 months later. Results. A mixed-effects general linear model revealed similar positive change in tactile sensitivity regardless of the type of training. On average, participants were able to detect a stimulus that was 32% and 33% less after training and at 6-month follow-up, respectively. One-third of participants experienced recategorization of their level of somatosensory impairment (e.g., regained protective sensation) following training. Poorer tactile sensation at baseline was associated with greater change. Conclusions. About one-third of individuals with mild/moderate chronic hemiparesis experience sustained improvements in tactile sensation following motor rehabilitation, regardless of the extent of tactile input in the rehabilitation program. Potential for sensory improvement is an additional motivator for those post-stroke. Characteristics of those who improve and mechanisms of improvement are important future questions. Clinicaltrials.gov NCT02631850

Nerve merging repair in the replantation of a severed limb with defects in multiple nerves: five cases and long-term follow-up

BackgroundRepairing all nerves is challenging in cases of upper arm avulsion combined with defects in multiple nerves because the donor area for autogenous nerve transplantation is limited and the outcomes of long-segment allogeneic nerve transplantation are poor. Based on the principle of magnified nerve regeneration, we present a method called nerve merging repair, the feasibility of which needs to be confirmed in clinical practice.MethodsThe nerve merging repair method relies on the use of fewer proximal nerves to innervate more distal nerves and depends mainly on whether the radial nerve (RN) can repair itself. In the case of defects in multiple nerves precluding RN self-repair, median-(median + radial) (M-(M + R)) repair is performed. If the RN can undergo self-repair, median-(median + ulnar) (M-(M + U)) or ulnar-(ulnar + median) (U-(U + M)) is used to repair the three nerves. Five cases were included in the study and involved the analysis of joint motor function, muscle strength and sensory recovery of the affected limb.ResultsThe replanted limb survived in all 5 cases. Follow-up visits were conducted with the patients for 51–80 months, during which they experienced satisfactory recovery of skin sensation, elbow flexion and extension and partial recovery of hand muscle strength.ConclusionsTo a certain extent, treatment with the nerve merging repair method improved the sensory and motor function of the affected limb and limited the loss of function of the donor nerve area. This intervention provides a new approach for repairing long-segment defects in multiple nerves caused by avulsion amputation of the upper limb.

Panaxydol Derived from Panax notoginseng Promotes Nerve Regeneration after Sciatic Nerve Transection in Rats.

Peripheral nerve regeneration is a coordinated process of Schwann cell (SC) reprogramming and intrinsic neuronal growth program activation. Panaxydol (PND) is a strong biologically active traditional Chinese medicine monomer extracted from Panax notoginseng rhizomes. In vitro, PND protects neurons and SCs from injury and stimulates the expression and secretion of neurotrophic factors (NTFs) by SCs. We hypothesized that PND may also promote peripheral nerve regeneration in adult animals. PND (10 mg/kg body weight) was injected intraperitoneally into the Sprague-Dawley (SD) rats for two consecutive weeks after sciatic nerve transection. The morphology of the repaired sciatic nerve was evaluated after 16 weeks, and sensory and motor function recovery was evaluated using functional and behavioral techniques. PND was biologically safe at an injection dose of 10 mg/kg/day. After 14 days, it significantly increased the myelination of regenerated nerve fibers, and promoted sensory and motor function recovery. In the early stage of injury, PND significantly upregulated the mRNA expression of brain-derived neurotrophic factor (BDNF) and its receptors in distal injured nerves, which may represent a possible mechanism by which PND promotes nerve regeneration in vivo. Our study demonstrated that PND leads to sensory and motor recovery in a sciatic nerve transection model rat. Furthermore, we showed that BDNF mRNA level was significantly increased in the injured distal nerve, potentially contributing to the functional recovery. Further research is warrantied to examine whether direct injection is a more efficient method to increase BDNF expression compared to an exogenous BDNF administration.

Prospect of Stem Cells as Promising Therapy for Brachial Plexus Injury: A Systematic Review.

BackgroundBrachial plexus injury is an advanced and devastating neurological injury, for which both nerve surgery and tendon transfers sometimes remain insufficient in restoring normal movement. Stem cell therapy may be applicable to rescue the injured motor neurons from degeneration which potentially improves muscle strength.Study DesignSystematic Review; Level of evidence V.Data SourcesA systematic literature search was conducted on PubMed (MEDLINE), EMBASE, the Cochrane Library, and Scopus using the terms (“stem cell”) AND (“brachial plexus”) as search keywords.MethodsThe process of study selection was summarized by PRISMA flow diagram. The study included in vivo and in vitro studies with English language, humans or animals with some brachial plexus injuries, interventions, some applications of stem cells to the groups of study, with functional, biomechanical, or safety outcomes.ResultsIn total, there were 199 studies identified from the literature sources where 75 articles were qualified for forward evaluation following selecting the titles and abstracts. Ten studies were finally included in this systematic review after full-text assessment. Stem cells can produce neurotrophic factors in vitro and in vivo in rats, and their level was increased after injury. Electrophysiological measurement showed that the intervention group had distinctly higher CMAP amplitude and evidently shorter CMAP latency than the model group. Application of bone marrow stem cells (BMSCs) showed an elevation in the numbers of axons and density of myelinated fibers, the density of nerve fibers, the diameter of regenerating axons, and a decrease in axonal degeneration. A study in humans indicated an improvement of the movements in a patient with traumatic total BPI after injection of Ad-MSC. It is associated with increased muscle mass and sensory recovery and also suggested that mononuclear cell injection enhances muscle regeneration and reinnervation in the partly denervated muscle of brachial plexus injury. Various muscle groups had obtained strength together with restoration, the muscle strength attained after the previous transplantation were preserved. The results of this review support stem cell treatment in brachial plexus injury.ConclusionThis review provides evidence of the positive effects of stem cell treatment in brachial plexus injury.

Neurodynamic Treatment Promotes Mechanical Pain Modulation in Sensory Neurons and Nerve Regeneration in Rats

Background: Somatic nerve injuries are a rising problem leading to disability associated with neuropathic pain commonly reported as mechanical allodynia (MA) and hyperalgesia. These symptoms are strongly dependent on specific processes in the dorsal root ganglia (DRG). Neurodynamic treatment (NDT), consisting of selective uniaxial nerve repeated tension protocols, effectively reduces pain and disability in neuropathic pain patients even though the biological mechanisms remain poorly characterized. We aimed to define, both in vivo and ex vivo, how NDT could promote nerve regeneration and modulate some processes in the DRG linked to MA and hyperalgesia. Methods: We examined in Wistar rats, after unilateral median and ulnar nerve crush, the therapeutic effects of NDT and the possible protective effects of NDT administered for 10 days before the injury. We adopted an ex vivo model of DRG organotypic explant subjected to NDT to explore the selective effects on DRG cells. Results: Behavioural tests, morphological and morphometrical analyses, and gene and protein expression analyses were performed, and these tests revealed that NDT promotes nerve regeneration processes, speeds up sensory motor recovery, and modulates mechanical pain by affecting, in the DRG, the expression of TACAN, a mechanosensitive receptor shared between humans and rats responsible for MA and hyperalgesia. The ex vivo experiments have shown that NDT increases neurite regrowth and confirmed the modulation of TACAN. Conclusions: The results obtained in this study on the biological and molecular mechanisms induced by NDT will allow the exploration, in future clinical trials, of its efficacy in different conditions of neuropathic pain.

Glibenclamide promoted functional recovery following sciatic nerve injury in male Wistar rats.

The impact of peripheral nerve damage on a patient's quality of life is severe. The most frequent peripheral nerve crush damage is a sciatic nerve injury. Previous research has shown that glibenclamide (GB) has neuroprotective properties in a variety of oxidative stress-related disorders, including Alzheimer and Parkinson. The goal of this study was to see how GB affected nerve regeneration and improved function of the sciatic nerve in a rat model following a crush injury. We evaluated motor function, sensory recovery, gene expression, and histomorphometry following damage at different time points. Additionally, we assessed atrophy in the gastrocnemius muscle using histology and mass ratio analyses. Our results suggest that 2, 4, 6, and 8weeks following glibenclamide therapy, promotes the recovery of motor and sensory function in the injured site. Following glibenclamid injection, the mRNA levels of neurotrophic factors (NGF and BDNF) are raised. According to histomorphometry assessment, glibenclamide injection also increased the number of myelinated fibers while decreasing their thickness. These results showed that glibenclamide therapy by decreasing the proinflammatory and oxidant factors may enhance the nerve regeneration. It is clear that more research is needed to confirm these findings.

Prospective randomized double blind study to evaluate the analgesic efficacy of low dose of intrathecal neostigmine in combination with fentanyl and bupivacaine for lower abdominal and lower limb surgery

More than 80% of patients undergoing surgical procedures under spinal anesthesia experience acute post-operative pain. The aim of the study was to compare the analgesic efficacy and side effects of addition of neostigmine to fentanyl and bupivacaine. 50 patients scheduled for elective lower abdominal and lower limb surgeries likely to finish within 3 hours, were put into two groups. 25 patients in each group aged between 18 to 60 years of either sex belonging to the ASA grade I & II. Group A was given Intrathecal Bupivacaine 12.5 mg (2.5 ml) + Fentanyl 20 µg (0.4 ml)+0.1 ml Normal Saline (Total 3 ml) and Group B was given Intrathecal Bupivacaine 12.5 mg (2.5 ml) + Fentanyl 20 µg (0.4 ml) + Neostigmine 1µg (0.1 ml) (Total 3 ml). Subjects were monitored for occurrence of any adverse events after spinal injection. We observed statistically significant difference between the two groups in the onset of sensory blockade and recovery of sensory blockade. Onset of sensory blockade was earlier in Group B and recovery time was prolonged in Group B. No difference was seen in maximal sensory blockade.

Minimally Invasive Corneal Neurotization Provides Sensory Function, Protects Against Recurrent Ulceration, and Improves Visual Acuity

To measure sensory recovery after minimally invasive corneal neurotization, and to identify and quantify the extent to which patient and technical factors influence sensory recovery, ulceration rate, and visual outcomes. Retrospective case series. This study included 23 patients with neurotrophic keratopathy who underwent indirect corneal neurotization. The primary outcome measure was corneal sensitivity with Cochet-Bonnet aesthesiometry (CBA), and the secondary outcome measure was epithelial breakdown. Over a 7-year period, 28 eyes of 23 patients (mean age, 15.6 ± 13.6 years) were included in the study. The CBA measurements improved from 3.5 ± 9.1 mm at baseline to 44.1 ± 18.2 mm at 24 months after surgery (P < .001). Maximum CBA was reached after 11.1 ± 6.2 months (median, 9 months). Compared to eyes neurotized with a contralateral donor nerve, eyes with an ipsilateral donor nerve achieved a higher mean CBA (36.0 ± 10.9 vs 10.4 ± 14.0 mm, P=.001) at 3 months. Both the number of fascicles (Spearman correlation coefficient, rs -0.474, P=.11) and insertions (rs -0.458, P=.014) negatively correlated with the final CBA. Nine eyes (32.1%) experienced at least 1 episode of epithelial breakdown after surgery. Visual acuity improved in the neurotized corneas from logMAR 0.57 ± 0.79 at baseline to 0.39 ± 0.66 at 12 months (P=.043). Corneal sensation improves over time after corneal neurotization. There is resultant improvement in visual acuity and protection against epithelial breakdown. It is important to maximize sensory recovery to protect against recurrent ulceration.

The outcome of gracilis muscle flap wrapping around the neourethra-native urethral anastomosis after radial forearm free flap phalloplasty on the incidence of fistula formation

ABSTRACT Introduction The radial artery-based free-flap phalloplasty (RFFP) is accompanied by high rates of fistula formation and urological complications. We thought to investigate the impact of pedicled gracilis muscle flap wrapping around the urethral anastomosis on the occurrence of fistula at the neourethra-native urethral junction. Materials and Methods Prospective study was conducted at the urology department of Cairo University Hospitals. Patients presenting with micropenis (stretched penile length ≤7 cm) underwent RFFP. The RFF was harvested from the non-dominant forearm after ensuring of good collateral supply to the hand. All patients underwent RFFP with pedicled gracilis muscle flap wrapping. Under microscopic guidance, the radial artery was anastomosed with the inferior epigastric artery, the cephalic vein with the great saphenous vein and the medial and the lateral ante-brachial nerves with the ilioinguinal nerve and the dorsal penile nerve, respectively. Data were reviewed for demographics and perioperative outcomes. Results Nineteen patients were included in the study with a median follow up of 11 months (3, 22). Median age of 26 yrs (16, 43), hospital stay was 7 days (7, 30) and. Indications for RFFP were: micropenis (40%), post-surgery crippled penis (25%), amputated penis (20%), aphallia (5%), epispadias (5%) and gender dysphoria (5%). Median ischemia time was 88 mins (60, 120), ebl was 600 cc (300, 2000) and operative time 11 hrs (8, 14). Intraoperative complications were a case of transection of the radial artery during graft harvesting, failure to tubularize the graft and significant blood loss during vaginectomy. Overall success rate was 70%. 5 cases had a complete success, only one case had a fistula at the neo-uretheral native urethral anastomosis, one patient had a distal fistula and another patient had a ring stricture at site of anastomosis. 8 cases were complicated by complete disruption of the urethra. 6 cases were complicated by total graft loss (2 cases due to arterial causes and 4 cases due to venous congestion). No donor site morbidity was noted. During follow up patients reported shortness in the mean length of the phallus was 2.1cms. All patients reported recovery of both general and erogenous sensations in the neo-phallus. The recovery of the general sensation (tactile stimulation and two-point discriminations) ranged between 2 to 4 weeks post-operatively while recovery of the erogenous sensation occurred between 8 to 16 weeks. Conclusion The use of pedicled garcilis flap during RFFP resulted in a fistulae rate of 20%. Disclosure Work supported by industry: no.

Clinical Assessment of Pain and Sensory Function in Peripheral Nerve Injury and Recovery: A Systematic Review of Literature.

Peripheral nerve injuries (PNIs) often present with variable symptoms, making them difficult to diagnose, treat, and monitor. When neurologic compromise is inadequately assessed, suboptimal treatment decisions can result in lasting functional deficits. There are many available tools for evaluating pain and functional status of peripheral nerves. However, the literature lacks a detailed, comprehensive view of the data comparing the clinical utility of these modalities, and there is no consensus on the optimal algorithm for sensory and pain assessment in PNIs. We performed a systematic review of the literature focused on clinical data, evaluating pain and sensory assessment methods in peripheral nerves. We searched through multiple databases, including PubMed/Medline, Embase, and Google Scholar, to identify studies that assessed assessment tools and explored their advantages and disadvantages. A total of 66 studies were selected that assessed various tools used to assess patient's pain and sensory recovery after a PNI. This review may serve as a guide to select the most appropriate assessment tools for monitoring nerve pain and/or sensory function both pre- and postoperatively. As the surgeons work to improve treatments for PNI and dysfunction, identifying the most appropriate existing measures of success and future directions for improved algorithms could lead to improved patient outcomes.

Comparing Autologous to Device-Based Breast Reconstruction: A Pilot Study of Return in Breast Sensation.

Poor breast sensation is common after mastectomy and reconstruction. In this study, we aim to define the temporal pattern of sensory changes after reconstruction and to compare the return in sensation between autologous and device-based reconstruction. Women undergoing mastectomy with immediate reconstruction, with either tissue expander (TE) or neurotized deep inferior epigastric perforator (DIEP) flap, were prospectively identified at their preoperative or postoperative visit at defined time points. Neurosensory testing was performed in 9 breast regions using the AcroVal pressure-specified sensory device to determine 1 point-static cutaneous thresholds. Sensitivity data were averaged between patients at each time point and plotted over time. Eighty-seven patients (153 breasts) were included in this study, including 41 women (75 breasts) with DIEP flap and 46 women (78 breasts) with TE. The groups were comparable in age, body mass index, breast size, chemotherapy, radiotherapy, and number of revisional breast surgeries (P > 0.05). Compared with preoperative baseline, mean cutaneous thresholds in DIEP flap patients were comparable in most outer breast regions at 18 months postoperatively and in the entire breast, except the inner inferior region, at 3 years (P > 0.05). In contrast, mean cutaneous thresholds in TE patients continued to be significantly worse in the entire breast at 5 years postoperatively compared with baseline (P < 0.05). Autologous breast reconstruction is superior in sensory recovery. Patients undergoing DIEP flap can expect sensory return to preoperative levels by 3 years, with sensation returning by 18 months in some areas of the breast. Patients undergoing device reconstruction should expect a slower and more unpredictable return in breast sensation.

Recovering the regenerative potential in chronically injured nerves by using conditioning electrical stimulation.

Chronically injured nerves pose a significant clinical challenge despite surgical management. There is no clinically feasible perioperative technique to upregulate a proregenerative environment in a chronic nerve injury. Conditioning electrical stimulation (CES) significantly improves sensorimotor recovery following acute nerve injury to the tibial and common fibular nerves. The authors' objective was to determine if CES could foster a proregenerative environment following chronically injured nerve reconstruction. The tibial nerve of 60 Sprague Dawley rats was cut, and the proximal ends were inserted into the hamstring muscles to prevent spontaneous reinnervation. Eleven weeks postinjury, these chronically injured animals were randomized, and half were treated with CES proximal to the tibial nerve cut site. Three days later, 24 animals were killed to evaluate the effects of CES on the expression of regeneration-associated genes at the cell body (n = 18) and Schwann cell proliferation (n = 6). In the remaining animals, the tibial nerve defect was reconstructed using a 10-mm isograft. Length of nerve regeneration was assessed 3 weeks postgrafting (n = 16), and functional recovery was evaluated weekly between 7 and 19 weeks of regeneration (n = 20). Three weeks after nerve isograft surgery, tibial nerves treated with CES prior to grafting had a significantly longer length of nerve regeneration (p < 0.01). Von Frey analysis identified improved sensory recovery among animals treated with CES (p < 0.01). Motor reinnervation, assessed by kinetics, kinematics, and skilled motor tasks, showed significant recovery (p < 0.05 to p < 0.001). These findings were supported by immunohistochemical quantification of motor endplate reinnervation (p < 0.05). Mechanisms to support the role of CES in reinvigorating the regenerative response were assessed, and it was demonstrated that CES increased the proliferation of Schwann cells in chronically injured nerves (p < 0.05). Furthermore, CES upregulated regeneration-associated gene expression to increase growth-associated protein-43 (GAP-43), phosphorylated cAMP response element binding protein (pCREB) at the neuronal cell bodies, and upregulated glial fibrillary acidic protein expression in the surrounding satellite glial cells (p < 0.05 to p < 0.001). Regeneration following chronic axotomy is impaired due to downregulation of the proregenerative environment generated following nerve injury. CES delivered to a chronically injured nerve influences the cell body and the nerve to re-upregulate an environment that accelerates axon regeneration, resulting in significant improvements in sensory and motor functional recovery. Percutaneous CES may be a preoperative strategy to significantly improve outcomes for patients undergoing delayed nerve reconstruction.

Total Urethra and Penile Shaft Reconstruction with Combined Pedicled Anterolateral Thigh Flap and Radial Forearm Free Flap after Total Penectomy.

Total reconstruction of the penis (TPR) represents a challenge for urologists and plastic surgeons, especially when urethral length is severely reduced. We here describe, for the first time in an oncologic scenario, a double flap phalloplasty using a pedicled anterolateral thigh (ALT) flap for penile reconstruction and a radial forearm free flap (RFFF) for complete neourethra and glans reconstruction following penile amputation. A 48-year-old patient came to our department following a total penectomy with inferior urethral derivation. The indication for a double flap phalloplasty was posed as only way to fully reconstruct the urethra on its length avoiding possible complications of single flap reconstruction using tube-into-tube technique. Both flaps healed uneventfully with no neourethral strictures or fistulas described. At 18 months follow-up, the patient was extremely satisfied with the aesthetic result and was able to void in standing position. We think that a double free tissue transfer for TPR should be considered, particularly when a urethral length > 14 cm needs to be reconstructed. While the pedicled ALT can be used to reconstruct a proper penile shaft with an easily concealed scar, the RFFF can provide adequate neourethra length with satisfactory sensory recovery at the neoglans.