Reconstruction of Quadriceps Function Using a Single Functional Gracilis Muscle Transfer With an Adductor Longus Nerve to Femoral Nerve Branch of the Rectus Femoris Nerve Transfer.

BACKGROUND: A femoral nerve injury may result in cutaneous sensory disturbances of the anteromedial thigh and complete paralysis of the quadriceps femoris muscles resulting in an inability to extend the knee. The traditional mainstay of treatment for femoral neuropathy is early physiotherapy, knee support devices, and pain control. Case reports have used the anterior division of the obturator nerve as a donor nerve to innervate the quadriceps femoris muscles; however, a second nerve transfer or nerve grafting is often required for improved outcomes. We suggest a novel technique of combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer to restore the strength and stability of the quadriceps muscles. METHODS: This is a case series describing the use of a pedicled gracilis muscle transposed into the rectus femoris position with a concomitant nerve transfer from the adductor longus nerve branch into the rectus femoris nerve branch to restore quadriceps function after iatrogenic injury (hip arthroplasty) and trauma (gunshot wound). RESULTS: With electrodiagnostic confirmation of severe denervation of the quadriceps muscles and no evidence of elicitable motor units, 2 patients (average age, 47 years) underwent a quadriceps muscle reconstruction with a pedicled, innervated gracilis muscle and an adductor longus to recuts femoris nerve transfer. At 1 year follow-up, the patients achieved 4.5/5 British Medical Research Council full knee extension, a stable knee, and the ability to ambulate without an assistive aid. CONCLUSIONS: The required amount of quadriceps strength necessary to maintain quality of life has not been accurately established. In the case of femoral neuropathy, we assumed that a nerve transfer alone and a gracilis muscle transfer alone would not provide enough stability and strength to restore quadriceps function. We believe that the restoration of the quadriceps function after femoral nerve injury can be achieved by combining an innervated, pedicled gracilis transfer with an adductor longus to rectus femoris nerve transfer with low morbidity and no donor defects.

Computed Tomographic Angiography Used for Localization of the Cutaneous Perforators and Selection of Anterolateral Thigh Flap "Bail-Out" Branches.

BACKGROUND: The purpose of this study was to evaluate the territory supplied by the lateral circumflex femoral artery for the consistency of a proximal perforator that could be used as an alternative pedicle for the anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of the perforator used to develop the initial surgical plan. It is hypothesized that a consistent "bail-out" perforator supplying the proximal thigh would facilitate a simpler anterolateral thigh flap harvest, with minimal modification to flap design. METHODS: Computed tomographic images of 9 fresh cadavers were imported using Materialize's Interactive Medical Imaging Control System software to create surface-rendered 3-dimensional reconstructions of 15 lower limbs. Perforators emerging proximally and laterally to a 3-cm radius circle drawn at the midpoint of the anterior superior iliac spine and superolateral patella were considered potential bail-out perforators and evaluated for their number emerging diameter, length, course, and location relative to the anterior superior iliac spine. RESULTS: An average of 2.9 ± 1.8 perforators per limb were identified. Mean pedicle length was 111 ± 20 mm, measured from the origin in the lateral circumflex femoral artery to where the perforators emerged through the deep fascia directly overlying the thigh muscles. Average diameter at origin in the lateral circumflex femoral artery was 2.8 ± 0.8 mm, and that at emergence through the deep fascia was 1.1 ± 0.3 mm. Vessel course was predominantly musculocutaneous (90%). CONCLUSIONS: A significant bail-out perforator routinely supplies the proximal anterolateral thigh and may be used as an alternative vascular pedicle for an anterolateral thigh flap if a tedious intramuscular course is encountered during elevation of a perforator identified within the conventional landmarks (3-cm radius circle at the midpoint of the anterior superior iliac spine and superolateral patella).

A Limited Submuscular Direct-to-Implant Technique Utilizing AlloMax.

This study evaluates a novel limited submuscular direct-to-implant technique utilizing AlloMax where only the upper few centimeters of the implant is covered by the pectoralis, whereas the majority of the implant including the middle and lower poles are covered by acellular dermal matrix. METHODS: The pectoralis muscle is released off its inferior and inferior-medial origins and allowed to retract superiorly. Two sheets of AlloMax (6 × 16 cm) are sutured together and secured to the inframammary fold, serratus fascia, and the superiorly retracted pectoralis. Thirty-seven breasts in 19 consecutive patients with follow-up at 6 months were reviewed. RESULTS: Nineteen consecutive patients with 37 reconstructed breasts were studied. Average age was 50 years, average BMI was 24.3. Ptosis ranged from grade 0-III, and average cup size was B (range, A-DDD). Early minor complications included 1 seroma, 3 minor postoperative hematomas managed conservatively, and 3 minor wound healing problems. Three breasts experienced mastectomy skin flap necrosis and were managed with local excision. There were no cases of postoperative infection, red breast, grade III/IV capsular contractures, or implant loss. A single patient complained of animation postoperatively. One patient desired fat grafting for rippling. CONCLUSIONS: The limited submuscular direct-to-implant technique utilizing AlloMax appears to be safe with a low complication rate at 6 months. This technique minimizes the action of the pectoralis on the implant, reducing animation deformities but still providing muscle coverage of the upper limit of the implant. Visible rippling is reduced, and a vascularized bed remains for fat grafting of the upper pole if required.

Excision With Interpositional Nerve Grafting: An Alternative Technique for the Treatment of Morton Neuroma.

INTRODUCTION: "Morton neuroma" is a common cause of forefoot pain with numbness frequently occurring in the distribution of the third common digital nerve. After the failure of nonoperative measures, decompression with excision of the neuroma is common practice. Residual numbness and recurrent pain has been reported as a consequence of this treatment option. This study describes excision of the neuroma with interpositional nerve grafting as a treatment option for Morton neuroma. This proposed technique has the benefit of reducing pain, reducing recurrent secondary neuromas and restoring postexcision sensory deficits. METHODS: A retrospective chart review of patients who underwent elective primary excision of a Morton neuroma with interpositional nerve grafting was undertaken. Patient demographics, surgical technique, and clinical outcomes, such as pain, neuroma recurrence, 2-point discrimination, numbness, and weight-bearing status at minimum of 1 year postoperation, are reported. RESULTS: Eight patients (9 neuromas) underwent excision of the Morton neuroma with interpositional nerve grafting after failing nonoperative measures. At final follow-up, all patients had improvement of pain and there were no neuroma recurrences. Sensation to the grafted hemi-toe returned in all but 1 case. All patients returned to full weight-bearing status. Although no major complications were reported, wound dehiscence secondary to a hematoma occurred in 1 case. CONCLUSIONS: Excision and interpositional nerve grafting is an effective treatment for Morton neuroma as it alleviates pain, numbness and restores sensation with minimal morbidity and complications.

Axillary hyperhidrosis: a 5-year review of treatment efficacy and recurrence rates using a new arthroscopic shaver technique.

BACKGROUND: Axillary hyperhidrosis is a chronic condition characterized by excess axillary perspiration. This results in considerable patient morbidity, with no consistently efficacious medical or surgical treatment method described in the literature. METHODS: All cases of axillary hyperhidrosis over a 5-year period were reviewed retrospectively. Data were gathered by a chart review and telephone interview. Inclusion criteria included primary hyperhidrosis, failed conservative therapy, no prior surgical therapy, surgical management using a new arthroscopic shaver technique (R.L.B.-S.), and 6 months of postoperative follow-up. The technique used was consistent between surgeons. Sweating severity was assessed using a subjective numerical rating scale ranging from 1 to 10. Patient demographics, symptom history, results, and complications were analyzed. RESULTS: Average follow-up for 50 patients meeting the inclusion criteria was 28 months. The subjective severity scale demonstrated severity of 9.8 of 10 preoperatively and 2.3 of 10 postoperatively. Three patients (6 percent) reported mild recurrence of symptoms (4.6 of 10), which was not severe enough to seek further treatment. The average follow-up of those patients was 18.5 months. An overall subjective satisfaction of 96 percent was found, with a treatment success rate of 94 percent. Complications were minimal and self-limiting. The average time away from employment was 3.9 days and the average surgical operating room time was 46 minutes. CONCLUSIONS: The authors' new arthroscopic shaver technique is efficacious, with no significant morbidity, a 96 percent satisfaction rate, a subjectively measured 75 percent reduction of sweat, and a recurrence rate of only 6 percent. For cases of primary hyperhidrosis affecting the axilla not amenable to conservative treatment, the authors recommend an arthroscopic shaver technique as the first-line treatment of choice.