Normal sensorimotor plasticity in complex regional pain syndrome with fixed posture of the hand.

BACKGROUND: Movement disorders associated with complex regional pain syndrome type I have been a subject of controversy over the last 10 years regarding their nature and pathophysiology, with an intense debate about the functional (psychogenic) nature of this disorder. The aim of this study was to test sensorimotor plasticity and cortical excitability in patients with complex regional pain syndrome type I who developed a fixed posture of the hand. METHODS: Ten patients with complex regional pain syndrome type I in the right upper limb and a fixed posture of the hand (disease duration less than 24 months) and 10 age-matched healthy subjects were enrolled. The following parameters of corticospinal excitability were recorded from the abductor pollicis brevis muscle of both hands by transcranial magnetic stimulation: resting and active motor thresholds, short-interval intracortical inhibition and facilitation, cortical silent period, and short- and long-latency afferent inhibition. Sensorimotor plasticity was tested using the paired associative stimulation protocol. RESULTS: Short-interval intracortical inhibition and long-latency afferent inhibition were reduced only in the affected right hand of patients compared with control subjects. Sensorimotor plasticity was comparable to normal subjects, with a preserved topographic specificity. CONCLUSIONS: Our data support the view that motor disorder in complex regional pain syndrome type I is not associated with abnormal sensorimotor plasticity, and it shares pathophysiological abnormalities with functional (psychogenic) dystonia rather than with idiopathic dystonia. © 2016 International Parkinson and Movement Disorder Society.

A free vein graft cap influences neuroma formation after nerve transection.

INTRODUCTION: : Neuroma formation is a major problem in nerve surgery and consensus about its prevention has not been reached. It has been suggested that vein covering can reduce neuroma formation in transected nerves. In this article, the Authors propose an easy and novel method of covering by nerve stump capping with a free vein graft. METHODS: : Neuroma-like lesions were created on the rat thigh sectioning the femoral nerve above its division in 16 animals. The proximal nerve stump was invaginated into the lumen of a 1.5 cm long femoral free vein graft on the right side, and the vein was closed on itself by microsurgical sutures to form a cap for the nerve stump. On the left side acting as the control neuroma, the nerve was cut and left uncovered. Histological and immunohistochemical assessment was used to quantify the degree of neuroma formation. RESULTS: : Significant differences were found in both neuroma size and axon-glia organization between the treated and control sides indicating that free vein graft capping reduced neuroma formation in comparison to uncovered nerve stumps. CONCLUSIONS: : Our results confirm that vein-covering of a transected nerve stump can be effective in reducing neuroma formation. Moreover, unlike previous works that buried the nerve into an adjacent vein left in place, our experiments showed that also the use of a free vein graft cap can hinder neuroma formation. Although translation of rat experiments to the clinics should be dealt with caution, our data suggest a careful clinical use of the technique. (c) 2009 Wiley-Liss, Inc. Microsurgery, 2009.

An anterior-lateral thigh perforator flap on a recipient brachial-radial vein graft for complex wound reconstruction: a case report.

A case of challenging microsurgical reconstruction of a difficult defect in a radiated upper limb is reported. A difficult wound, with tendon and bone exposition, developed on the dorsum of the forearm in a 76-year-old patient; she had been radiated since almost 50 years and her left hand had also been revascularized twice with venous grafts between the humeral artery and the superficial palmar arch. After failure of a local flap, an anterior-lateral thigh perforator flap was successfully transferred with end-to-side anastomoses on the arterialized venous graft. Up to date follow-up shows a good outcome. The Authors discuss the case and review the indications for microsurgical reconstruction in difficult wounds after radiation and ischemic limb conditions.

The distally based sural flap for lower leg reconstruction: versatility in patients with associated morbidity.

INTRODUCTION: Coverage of soft tissue defects in the lower leg is often made by use of free flap, also because of the improving of anaesthesiology techniques in the last decades. However, there are disadvantages in the use of free flaps like the need for a remote donor site, increased operative time, use of a major vessel to the leg, and microsurgical skills. Besides these, trauma in the lower limb are often cause of damage for a major vessels of the leg, so the use of free flaps in these patients may be related to an higher incidence of complications; also associated pathologies, like diabetes and vascular pathology, can increase the incidence of complications when a free flap is utilized. In all these cases local fascio-cutaneous flaps, like the sural reverse flap, because of their easy and short time harvesting, can be a very good alternative to free flaps. Superficial sural artery flap is a adipofasciocutaneous flap based on the vascular axis of the sural nerve, which gets reverse blood flow through communication with the perforating branch of the peroneal artery, situated in the region of lateral malleolar gutter. PATIENTS AND METHODS: Between 2000 and 2005, 11 patients, mean age 68 (range 58-78 years), were treated at the Plastic and Reconstructive Surgery Unit of Messina University, for soft tissue defects of lower limb and foot, using the distally based sural artery flap. The defects were related to post-traumatic damage of soft tissue, diabetic and vascular ulcers, osteomyelitis and oncological resection. Mean follow-up time was 20 months (range 6-55 months). All patients were pre-operatively assessed for vascular patency of peroneal axis and associated morbidity that could increase risk offlap necrosis. This included diabetes mellitus type II, osteomyelitis and peripheral arterial diseases. RESULTS: All flaps survived with the exception of one that sustained partial skin necrosis, in the ratio of 25% of the skin island. All defects were covered with no major complications and none of the patients required a blood transfusion. Moreover aesthetic results were good with satisfaction of all the patients. CONCLUSION: In our cases we found the sural reverse flap to have a good reliability with low incidence of complication and surgical outcomes. This flap is an excellent option for covering defects of minor deficiency of skin in the third distally of lower limb, ankle and heel. It allows rapid, reliable coverage of defects extending as far distally as the forefoot. Because of the sparing of major vessels, the short surgery time in harvesting the flap, and the good vascular pattern of the flap, we retain the flap a first choose technique for reconstruction in lower leg, especially in politrauma and in patients with associated pathology as vascular diseases or diabetes.

Ulnar nerve repair by end-to-side neurorrhaphy on the median nerve with interposition of a vein: an experimental study.

Our study used a rat animal model to verify that Schwann cell migration, collateral axonal sprouting, and regeneration were not hindered by interposition of a 10-mm vein segment between the distal stump of the transected ulnar nerve and the donor median nerve in end-to-side reconstruction. Reconstructed nerves were withdrawn at 7, 14, 30, and 60 days after surgery, then analyzed by confocal laser microscopy after immunolabeling with anti-neurofilament-200 kD (an axonal marker) and anti-S100 (a glial marker) antibodies. Results are reported at 7, 14, 30, and 60 days after surgery. Our observations indicate that chemotactic factors that stimulate end-to-side nerve regeneration can exert their action at this distance. These findings suggest a possible clinical application for this surgical technique in cases when the severed nerve stump is far from the potential donor nerve.

Solitary asymptomatic nodule of the great toe.

Subungual exostosis is a benign osteocartilaginous tumor of the ungual apparatus, particularly of the toes. It affects both sexes equally, more frequently in the second and third decades of life. We describe a 6-year-old girl who came to our attention because of the enlargement of a pinkish nodule in the distal part of the nail bed of the first toe, progressively elevating the nail plate. History, X-ray imaging and histopathologic examination led us to confirm our clinical suspicion, excluding any other possible cause of the subungual mass. The peculiar features of this clinical entity, and the possibility of effective treatment by practical surgical techniques, are discussed.