Assessment of Conduit-Assisted Primary Nerve Repair Strength With Varying Suture Size, Number, and Location.

Background: Outcomes following digital nerve repair are suboptimal despite much research and various methods of repair. Increased tensile strength of the repair and decreased suture material at the repair site may be 2 methods of improving biologic and biomechanical outcomes, and conduit-assisted repair can aid in achieving both of these goals. Methods: Ninety-nine fresh-frozen digital nerves were equally divided into 11 different groups. Each group uses a different combination of number of sutures at the coaptation site and number of sutures at each end of the nerve-conduit junction, as well as 2 calibers of nylon suture. Nerves were transected, repaired with these various suture configurations using an AxoGuard conduit, and loaded to failure. Results: The 2-way analysis of variance (ANOVA) showed that repairs performed with 8-0 suture have significantly higher maximum failure load compared with 9-0 suture repairs (P < .01). Increasing the number of sutures in the repair significantly increased the maximum failure load in all groups regardless of suture caliber used (P < .01). Repairs with 9-0 suture at the coaptation site did not jeopardize repair strength when compared with 8-0 suture. Conclusions: Conduit-assisted primary digital nerve repairs with 8-0 suture increases the maximum load to failure compared with repairs with 9-0 suture, as does increasing the overall number of sutures. Using 9-0 suture at the coaptation site with 8-0 suture at the nerve-conduit junction does not jeopardize tensile strength when compared with similar repairs using all 8-0 suture and may decrease inflammation at the repair site while still achieving sufficient tensile strength.

High Thoracic Disc Herniation Causing Horner Syndrome with the Intraoperative Finding of Conjoined Nerve Root Compression: A Case Report.

CASE: A 29-year-old man presented with right medial arm pain with paresthesia, as well as right-sided ptosis, miosis, and anhidrosis. Magnetic resonance imaging revealed a right paracentral disc herniation at the T1-T2 level. The patient underwent a hemilaminectomy with a medial facetectomy through a posterolateral approach to the T1-T2 disc space, followed by a discectomy. Intraoperative findings were notable for a conjoined nerve root. CONCLUSION: Although high thoracic disc herniation is rare, its diagnosis should be considered when patients present with radicular arm pain and Horner syndrome. A high index of suspicion should be maintained for nerve root anomalies to limit iatrogenic injury and to ensure successful decompression.

A knotless flexor tendon repair technique using a bidirectional barbed suture: an ex vivo comparison of three methods.

BACKGROUND: Flexor tendon repairs using conventional suture require knots that enlarge the cross-sectional area at the repair site. This enlargement increases the force of finger flexion and jeopardizes the integrity of a nascent tendon repair during rehabilitation. The authors hypothesized that a knotless flexor tendon repair using bidirectional barbed suture has similar strength and with reduced cross-sectional area compared with traditional techniques. METHODS: Sixty-six fresh porcine flexor digitorum profundus tendons were divided randomly into three groups. Tendons were transected and repaired with one of the following techniques: two-strand Kessler technique, four-strand Savage technique, or four-strand knotless technique. The cross-sectional area of each tendon was calculated at the repair site before and after repair. All tendons underwent mechanical testing to assess the 2-mm-gap formation force and ultimate strength. RESULTS: The 2-mm-gap formation force and ultimate strength of the Savage and knotless technique groups were not significantly different; however, both were significantly greater than those of the Kessler repair group (p<0.05). The repair-site cross-sectional area of tendons repaired with the knotless technique was significantly smaller than that of tendons repaired with the Kessler or Savage technique (p<0.01). Tendons repaired with the knotless technique also had a significantly smaller change in repair-site cross-sectional area (p<0.01). CONCLUSIONS: The authors demonstrate that knotless flexor tendon repair with barbed suture has equivalent strength and reduced repair-site cross-sectional area compared with traditional techniques. The smaller tendon profile may decrease gliding resistance, thus reducing the risk for postsurgical tendon rupture during rehabilitation.

The role of nerve transfers for C5-C6 brachial plexus injury in adults.

The brachial plexus consists of nerve roots C5-T1. Upper brachial plexus roots (C5-C6) innervate proximal muscles of the shoulder and upper arm. Injuries causing root avulsion or rupture require intensive treatment and significantly impact patients' quality of life. Nerves regenerate extremely slowly and without treatment, patients with upper brachial plexus lesions may lose motor function distal to the injury. Upper brachial plexus reconstruction using nerve transfers is a new method to bypass damaged areas thereby allowing patients to regain critical arm functions faster. We present a review of brachial plexus cadaveric anatomy, reconstruction transfer techniques, and management.

Lower eyelid reconstruction following Mohs surgery.

Lower eyelid defects resulting from Mohs micrographic surgery can be challenging to repair. These repairs are fraught with potential complication due to the lower eyelid's complex anatomy and defect variability. A single "cookie-cutter" treatment regimen does not exist because patients and defects vary. Surgical closure techniques include primary closure, eyelid advancement, rotational flaps, full thickness skin grafts, and/or allografts. We present a discussion of lower eyelid reconstruction including relevant anatomy, physical signs, and treatment options with examples.