Nerve transfer in the spastic upper limb: anatomical feasibility study.

PURPOSE: Nerve transfers represent an innovative tool in the surgical treatment of upper limb paralysis. Well-documented for brachial plexus sequalae and under evaluation for tetraplegic patients, they have not yet been described for spastic upper limbs. The typical spastic deformity involves active and spastic flexor, adductor and pronator muscles, associated with paralysed extensor and supinator muscles. Experience with selective neurectomy has shown an effective decrease in spasticity together with preservation of muscle strength. We conceptualized a combination of neurectomy and nerve transfer, by performing a partial nerve transfer from a spastic elbow flexor muscle to a paralyzed wrist extensor muscle, hypothesizing that this would reduce the spasticity of the former and simultaneously activate the latter. METHODS: Ten cadaveric dissections were performed in order to establish the anatomic feasibility of transferring a motor branch of the brachioradialis (BR) onto the branch of the extensor carpi radialis longus (ECRL) or brevis (ECRB). We measured the emergence, length, muscle entry point and diameter of each branch, and attempted the transfer. RESULTS: We found 1-4 motor nerve for the BR muscle and 1-2 for the ECRL muscle. In all cases, the nerve transfer was achievable, allowing a satisfactory coaptation. The ECRB branch emerged too distally to be anastomosed to one of the BR branches. CONCLUSION: This study shows that nerve transfers from the BR to the ECRL are anatomically feasible. It may open the way to an additional therapeutic approach for spastic upper limbs.

Meningococcaemia causing necrotizing cellulitis associated with acquired complement deficiency after gastric bypass surgery: a case report.

BACKGROUND: Neisseria meningitidis has rarely been described as an agent of necrotic soft tissue infection. CASE PRESENTATION: We report a case of a septic shock with necrotizing cellulitis due to Neisseria meningitidis serogroup W, treated by urgent extensive surgical debridement followed by skin grafts. The invasive meningococcal disease occurred together with a complement deficiency, possibly acquired after bypass surgery that took place 1 year before. CONCLUSIONS: Necrotic tissue infections should be considered part of the invasive meningococcal diseases spectrum and should prompt clinicians to look for complement deficiencies. Gastric bypass surgery associated malnutrition may be implicated but further verification is needed.

Anatomical Study of Lumbar Artery Perforators in Male Subjects.

INTRODUCTION: The lumbar artery perforator (LAP) flap takes an important place in lumbosacral reconstruction and in breast reconstruction. Although studies on the location of lumbar perforators in women are common, no anatomical study has focused solely on male subjects. Our objective is to facilitate the surgical approach to the LAP flap in male subjects by precisely ascertaining the characteristics of the perforators. METHODS: We performed a retrospective review of computed tomographic angiography images of a cohort of 30 patients evaluating the perforator position from the 4 lumbar arteries. In addition, 4 characteristics were studied: the length, the diameter, the path of the lumbar pedicle, and the thickness of tissues available for transfer. RESULTS: One hundred five lumbar perforating vessels were analyzed on 60 posterior hemi-bodies, of which 86% came from the third and fourth lumbar arteries. The average location was situated 7.4 cm from the midline and in a 6-cm vertical wide area. The position of the lumbar perforator was independent of body mass index, abdominal circumference, and subject size. Our results, compared to previous studies, show no difference in this position between men and women. CONCLUSIONS: The LAP flap is useful for regional reconstructions and as a free flap for both women and men. We provide male-specific tracking values for the dissection of lumbar perforating vessels. Dominant perforators were found to be situated in a wide region of 4 cm × 6 cm in the lumbosacral region at 7.4 cm from the midline.

Surgical Fixation of Metacarpophalangeal Collateral Ligament Rupture of the Fingers.

BACKGROUND: Collateral ligament injury of the metacarpophalangeal joint of the fingers is underreported in the literature and widely underestimated by the medical community. Here, the authors present results from a large series of patients and review factors influencing success of surgery. METHODS: The authors performed a retrospective study of 46 patients who underwent surgical fixation of the metacarpophalangeal collateral ligament using bone anchor in an acute or chronic setting. The diagnosis was predominantly clinical, based on laxity testing of the joint. The authors collected demographic data and intraoperative findings and postoperative results. RESULTS: Following surgery, with a median follow-up of 17 months, all patients presented with a stable joint and complete resolution of pain. The mean flexion of the metacarpophalangeal joint was 77.11 degrees, and mean extension was 0.84 degrees. The authors measured the injured grip strength at a mean of 88.52 percent of the opposite hand, and the mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score used to evaluate disability was 9.56 on a scale of 100 (with 100 being complete disability). CONCLUSIONS: Surgical treatment of metacarpophalangeal collateral ligament rupture of the fingers is a safe technique that gives reproducible positive results in terms of mobility, strength, and disability scale score. The authors' results show that anchoring of the ligament should be performed even with prolonged time from injury to surgery.

Selection criteria for surgical treatment of pudendal neuralgia.

AIMS: Pudendal neuralgia is the clinical expression of a chronic compression of the pudendal nerve. The diagnosis is based on a set of five criteria, called Nantes criteria. Four of the criteria are clinical and the last requires evaluation of the anesthetic response to CT-guided infiltration of the pudendal nerve. The aim of our study is to evaluate the relevance of anesthetic test response to select patients for surgery, and whether this criterion can be used to predict its success. METHODS: Retrospective analysis of a cohort of 34 patients undergoing surgical treatment. In our cohort, we included six patients with negative CT-guided pudendal nerve infiltration test. RESULTS: Of the 28 patients that met all five Nantes criteria, 64% (18 patients) responded well to surgery. In contrast, 100% of the six patients with a negative anesthetic test failed to show an amelioration of symptoms after surgical treatment (P = 0.006). In our analysis, there was no significant difference in surgery response when men were compared to women (P = 0.387), when procedure was unilateral or bilateral (P = 0.562), or when duration of symptoms was long (P = 0.412). We observed a difference in terms of age between the group of responders and non-responders, although this difference did not reach the threshold of significance (P = 0.216). CONCLUSIONS: The selection of candidates for surgery should always include a single diagnostic anesthetic injection of the pudendal nerve, as the fifth of the Nantes criteria is an effective predictor of the success of surgery. Neurourol. Urodynam. 36:663-666, 2017. © 2016 Wiley Periodicals, Inc.