Rehabilitation Surgery for Peripheral Facial Nerve Injury after Facial Trauma.

Introduction Facial trauma can cause damage to the facial nerve, which can have negative effects on function, aesthetics, and quality of life if left untreated. Objective To evaluate the effectiveness of peripheral facial nerve direct end-to-end anastomosis and/or nerve grafting surgery for patients with facial nerve injury after facial trauma. Methods Fifty-nine patients with peripheral facial nerve paralysis after facial injuries underwent facial nerve rehabilitation surgery from November 2017 to December 2021 at Ho Chi Minh City National Hospital of Odontology. Results All 59 cases of facial trauma with damage to the peripheral facial nerve underwent facial nerve reconstruction surgery within 8 weeks of the injury. Of these cases, 25/59 (42.3%) had end-to-end anastomosis, 22/59 (37.3%) had nerve grafting, and 12/59 (20.4%) had a combination of nerve grafting and end-to-end anastomosis. After surgery, the rates of moderate and good recovery were 78.4% and 11.8%, respectively. All facial paralysis measurements showed statistically significant improvement after surgery, including the Facial Nerve Grading Scale 2.0 (FNGS 2.0) score, the Facial Clinimetric Evaluation (FaCE) scale, and electroneurography. The rate of synkinesis after surgery was 34%. Patient follow-up postoperatively ranged from 6 to > 36 months; 51 out of 59 patients (86.4%) were followed-up for at least 12 months or longer. Conclusion Nerve rehabilitation surgery including direct end-to-end anastomosis and nerve grafting is effective in cases of peripheral facial nerve injury following facial trauma. The surgery helps restore nerve conduction and improve facial paralysis.

Role of tactile stimulation during the preweaning period on the development of the peripheral sensory sural (SU) nerve in adult artificially reared female rat.

Maternal deprivation, as a result of the artificial rearing (AR) paradigm, disturbs electrophysiological and histological characteristics of the peripheral sensory sural (SU) nerve of infant and adult male rats. Such changes are prevented by providing tactile or social stimulation during isolation. AR also affects the female rat's brain and behavior; however, it is unknown whether this early adverse experience also alters their SU nerve development or if tactile stimulation might prevent these possible developmental effects. To assess these possibilities, the electrophysiological and histological characteristics of the SU nerve from adult diestrus AR female rats that: (i) received no tactile stimulation (AR group), (ii) received tactile stimulation in the anogenital and body area (AR-Tactile group), or (iii) were mother reared (MR group) were determined. We found that the amplitude, but not the area, of the evoked compound action potential response in SU nerves of AR rats was lower than those of SU nerves of MR female rats. Tactile stimulation prevented these effects. Additionally, we found a reduction in the outer diameter and myelin thickness of axons, as well as a large proportion of axons with low myelin thickness in nerves of AR rats compared to the nerves of the MR and AR-Tactile groups of rats; however, tactile stimulation only partially prevented these effects. Our data indicate that maternal deprivation disturbs the development of sensory SU nerves in female rats, whereas tactile stimulation partially prevents the changes generated by AR. Considering that our previous studies have shown more severe effects of AR on male SU nerve development, we suggest that sex-associated factors may be involved in these processes.

The sural-sparing pattern in clinical variants and electrophysiological subtypes of Guillain-Barré syndrome / Padrão de preservação do sural nas variantes clínicas e subtipos eletrofisiológicos da síndrome de Guillain-Barré

Abstract Background Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis worldwide and can be classified into electrophysiological subtypes and clinical variants. Objective This study aimed to compare the frequency of the sural-sparing pattern (SSP) in subtypes and variants of GBS. Methods This retrospective cohort study analyzed clinical and electrophysiological data of 171 patients with GBS hospitalized in public and private hospitals of Natal, Rio Grande do Norte, Brazil, between 1994 and 2018; all cases were followed up by the same neurologist in a reference neurology center. Patients were classified according to electrophysiological subtypes and clinical variants, and the SSP frequency was compared in both categories. The exact Fisher test and Bonferroni correction were used for statistical analysis. Results The SSP was present in 53% (57 of 107) of the patients with acute inflammatory demyelinating polyradiculoneuropathy (AIDP), 8% (4 of 48) of the patients with axonal subtypes, and 31% (5 of 16) of the equivocal cases. The SSP frequency in the AIDP was significantly higher than in the axonal subtypes (p < 0.0001); the value was kept high after serial electrophysiological examinations. Only the paraparetic subtype did not present SSP. Conclusion The SSP may be present in AIDP and axonal subtypes, including acute motor axonal neuropathy, but it is significantly more present in AIDP. Moreover, the clinical variants reflect a specific pathological process and are correlated to its typical electrophysiological subtype, affecting the SSP frequency.

Resumo Antecedentes A síndrome de Guillain-Barré (GBS) é a causa mais comum de paralisia flácida aguda em todo o mundo e pode ser classificada em subtipos eletrofisiológicos e variantes clínicas. Objetivo Este estudo teve como objetivo comparar a frequência do padrão de preservação do sural (SSP) em subtipos e variantes de GBS. Métodos É um estudo de coorte retrospectivo que analisou dados clínicos e eletrofisiológicos de 171 pacientes com GBS internados em hospitais públicos e privados de Natal, Rio Grande do Norte, Brasil, entre 1994 e 2018. Todos os casos foram acompanhados pelo mesmo neurologista em centro de referência em neurologia. Os pacientes foram classificados de acordo com os subtipos eletrofisiológicos e variantes clínicas e a frequência do SSP foi comparada em ambas as categorias. O teste exato de Fisher e a correção de Bonferroni foram utilizados para análise estatística. Resultados O SSP esteve presente em 53% (57 de 107) dos pacientes com polirradiculoneuropatia desmielinizante inflamatória aguda (PDIA), em 8% (4 de 48) dos pacientes com subtipos axonais e em 31% (5 de 16) dos casos não definidos. A frequência do SSP no AIDP foi significativamente maior do que nos subtipos axonais (p < 0,0001); o valor manteve-se elevado após exames eletrofisiológicos seriados. Apenas o subtipo paraparético não apresentou SSP. Conclusão O SSP pode estar presente na PDIA e nos subtipos axonais, incluindo a neuropatia axonal motora aguda, mas está significativamente mais presente na PDIA. Além disso, as variantes clínicas refletem um processo patológico específico e estão correlacionadas ao seu subtipo eletrofisiológico típico, afetando a frequência do SSP.

Reconstrucción de neuroma de nervio radial superficial con injerto autólogo de nervio sural: presentación de dos casos / Reconstruction of painful neuroma of superficial branch of radial nerve after first dorsal compartment release: presentation of two cases

Resumen: Introducción: las lesiones iatrogénicas de nervio son complicaciones devastadoras de cualquier procedimiento quirúrgico. Ocasionan pérdida motora, dolor y formación de neuromas. En el abordaje para la liberación del primer compartimiento extensor de la muñeca, la rama superficial del nervio radial debe identificarse y protegerse previo a la liberación tendinosa. La lesión de este nervio sensitivo puede ocasionar dolor postoperatorio clínicamente significativo. La reconstrucción nerviosa con nervio autólogo ha demostrado en diversos escenarios buenos resultados para mejorar el dolor y recuperar la conducción nerviosa. Presentación de los casos: se presentan dos casos de mujeres adultas (F/47 y F/51) con antecedente de liberación de primer compartimiento dorsal de muñeca en otro centro hospitalario. Desarrollaron posteriormente dolor incapacitante y alodinia en sitio quirúrgico, así como limitación funcional. Fueron evaluadas y diagnosticadas como neuroma de rama superficial del nervio radial. No hubo mejoría con terapia física, por lo que se realizó reconstrucción nerviosa con injerto autólogo de nervio sural. Ambas pacientes tuvieron alivio del dolor de EVA 9-10 hasta EVA 1-2. A los cuatro meses de seguimiento, las dos mujeres recuperaron parcialmente la sensibilidad distal al sitio del neuroma, sin recurrencia del dolor presentado. Conclusiones: los neuromas son complicaciones devastadoras que ocurren con lesiones inadvertidas de nervios motores y sensitivos. La reconstrucción con nervio autólogo es una excelente opción para reconstrucción de pequeños tramos de nervio periférico.

Abstract: Introduction: nerve lesions are potentially catastrophic injuries. They can cause motor loss, severe pain and neuroma formation. The superficial branch of the radial nerve is at risk during first dorsal compartment release, its injury can cause neuroma formation. Autologous nerve reconstruction is the gold standard for treatment of small nerve gaps. Cases presentation: we present two cases of adult women (F/47 y F/51) with a prior history of first dorsal compartment release in another institution. Both patients developed debilitating neuropathic pain, as well as allodynia in the surgical site. They were diagnosed with superficial radial nerve neuroma. Oral medication and physical therapy was attempted without success. Surgical exploration and autologous nerve reconstruction was performed. Both patients had excellent relief of pain from visual analogue scale (VAS 9-10 to VAS 1-2). Postoperatively, both patients recovered partial sensitivity to pain in the zones distal to the repair. Conclusions: neuromas are feared complications that occur with unrecognized nerve lesions during surgery, they are difficult to treat and require multidisciplinary management. These two cases demonstrate that autologous nerve reconstruction is an excellent option for recovering function in small gaps of nerve tissue.

Variations in sural nerve formation and course in fetuses.

To investigate variations regarding the formation and course of the sural nerve (SN). We dissected 60 formalin-fixed Brazilian fetuses (n = 120 lower limbs) aged from the 16th to 34th weeks of gestational age. Three incisions were made in the leg to expose the SN, and the gastrocnemius muscle was retracted to investigate the SN course. Statistical analyses regarding laterality and sex were performed using the Chi-square test. Eight SN formation patterns were classified after analysis. Type 4 (in which the SN is formed by the union of the MSCN with the LSCN) was the most common SN formation pattern. Although there was no statistical association between the formation patterns and the lower limb laterality (p = 0.9725), there was as to sex (p = 0.03973), indicating an association between anatomical variation and sex. The site of branch joining was in the distal leg most time (53.75%). In all lower limbs, the SN or its branches crossed from the medial aspect of the leg to the lateral margin of the calcaneal tendon (CT). Most often, the SN is formed by joining the MSCN and the LSCN in the distal leg. The SN or its branches ran close to the saphenous vein, crossed the CT from medial to lateral, and distributed around the lateral malleolus.

Anatomical patterns of the sural nerve: a meta-analysis with clinical and surgical considerations.

BACKGROUND: The sural nerve (SN) supplies the posterolateral aspect of the leg and the lateral aspects of the ankle and foot and descends through the gastrocnemius muscle along the lower third of leg. Because in-depth knowledge about SN anatomy is essential for clinical and surgical approaches, our study aims to review SN anatomical patterns. METHODS: We searched the PubMed, Lilacs, Web of Science, and SpringerLink databases to find relevant articles for meta-analysis. We assessed the quality of the studies using the Anatomical Quality Assessment tool. We used proportion meta-analysis to analyze the SN morphological variables and simple mean meta-analysis to analyze the SN morphometric variables (nerve length and distance to anatomical landmarks). RESULTS: Thirty-six studies comprised this meta-analysis. Overall, Type 2A (63.68% [95% CI 42.36-82.64]), Type 1A (51.17% [95% CI 33.16-69.04]) and Type 1B (32.19% [95% CI 17.83-48.38]) were the most common SN formation patterns. The lower third of leg (42.40% [95% CI 32.24-52.86]) and middle third of leg (40.00% [95% CI 25.21-53.48]) were the most common SN formation sites. The pooled SN length from nerve formation to the lateral malleolus was 144.54 mm (95% CI 123.23-169.53) in adults, whereas the SN length was 25.10 mm (95% CI 23.20-27.16) in fetuses in the second trimester of gestation and 34.88 mm (95% CI 32.86-37.02) in fetuses in the third trimester of gestation. CONCLUSIONS: The most prevalent SN formation pattern was the union of the medial sural cutaneous nerve with the lateral sural cutaneous nerve. We found differences regarding geographical subgroup and subject age. The most common SN formation sites were the lower and middle thirds of the leg.

[Reconstruction of painful neuroma of superficial branch of radial nerve after first dorsal compartment release: presentation of two cases]. / Reconstrucción de neuroma de nervio radial superficial con injerto autólogo de nervio sural: presentación de dos casos.

INTRODUCTION: nerve lesions are potentially catastrophic injuries. They can cause motor loss, severe pain and neuroma formation. The superficial branch of the radial nerve is at risk during first dorsal compartment release, its injury can cause neuroma formation. Autologous nerve reconstruction is the gold standard for treatment of small nerve gaps. CASES PRESENTATION: we present two cases of adult women (F/47 y F/51) with a prior history of first dorsal compartment release in another institution. Both patients developed debilitating neuropathic pain, as well as allodynia in the surgical site. They were diagnosed with superficial radial nerve neuroma. Oral medication and physical therapy was attempted without success. Surgical exploration and autologous nerve reconstruction was performed. Both patients had excellent relief of pain from visual analogue scale (VAS 9-10 to VAS 1-2). Postoperatively, both patients recovered partial sensitivity to pain in the zones distal to the repair. CONCLUSIONS: neuromas are feared complications that occur with unrecognized nerve lesions during surgery, they are difficult to treat and require multidisciplinary management. These two cases demonstrate that autologous nerve reconstruction is an excellent option for recovering function in small gaps of nerve tissue.

INTRODUCCIÓN: las lesiones iatrogénicas de nervio son complicaciones devastadoras de cualquier procedimiento quirúrgico. Ocasionan pérdida motora, dolor y formación de neuromas. En el abordaje para la liberación del primer compartimiento extensor de la muñeca, la rama superficial del nervio radial debe identificarse y protegerse previo a la liberación tendinosa. La lesión de este nervio sensitivo puede ocasionar dolor postoperatorio clínicamente significativo. La reconstrucción nerviosa con nervio autólogo ha demostrado en diversos escenarios buenos resultados para mejorar el dolor y recuperar la conducción nerviosa. PRESENTACIÓN DE LOS CASOS: se presentan dos casos de mujeres adultas (F/47 y F/51) con antecedente de liberación de primer compartimiento dorsal de muñeca en otro centro hospitalario. Desarrollaron posteriormente dolor incapacitante y alodinia en sitio quirúrgico, así como limitación funcional. Fueron evaluadas y diagnosticadas como neuroma de rama superficial del nervio radial. No hubo mejoría con terapia física, por lo que se realizó reconstrucción nerviosa con injerto autólogo de nervio sural. Ambas pacientes tuvieron alivio del dolor de EVA 9-10 hasta EVA 1-2. A los cuatro meses de seguimiento, las dos mujeres recuperaron parcialmente la sensibilidad distal al sitio del neuroma, sin recurrencia del dolor presentado. CONCLUSIONES: los neuromas son complicaciones devastadoras que ocurren con lesiones inadvertidas de nervios motores y sensitivos. La reconstrucción con nervio autólogo es una excelente opción para reconstrucción de pequeños tramos de nervio periférico.

Characterization of the Sensory Nerve Action Potential of the Sural Nerve in Patients Over 60 Years of Age without Peripheral Neuropathy.

Demonstration of the possibility to obtain the sensory nerve action potential (SNAP) of sural nerve in patients over 60 years old, without peripheral neuropathy. Prospective study on 101 patients older than 60 years of age. Stimulation was applied 12 cm proximal to the recording point. Two hundred and two SNAPs of the sural nerve were collected with an average peak latency of 3.2 ms, onset latency of 2.6 ms, peak-to-peak amplitude of 15.2 µV and velocity of 45.7 m/s. It was possible to obtain the sural nerve SNAP in all tested patients older than 60, without peripheral neuropathy. The values obtained in this study prove to be useful as a reference in the evaluation of patients older than 60 years of age.

Surgical Anatomy of the Endoscopic Gastrocnemius Recession.

The objective of this investigation was to analyze the surgical anatomy of the endoscopic gastrocnemius recession procedure with reference to the curved nature of the aponeurosis. A consecutive series of 34 magnetic resonance imaging scans were evaluated under the direction of a musculoskeletal radiologist. An angular calculation of the effective curvature of the aponeurosis was measured 2 cm distal to the musculotendinous junction based on the maximal posterior excursion and terminal medial and lateral edges. A frequency count was additionally performed of the number of deep intramuscular septa extending from the aponeurosis, as well as a description of the location of the neurovascular bundle in this location. The mean effective curvature was 126.5 degrees (standard deviation [SD] = 6.3 degrees, range 115-143 degrees, 95% confidence interval 124.3-128.7 degrees). We observed an average of 1.2 (SD = 0.5, range = 0-2) deep intramuscular septa extending from the aponeurosis, and that 20.6% of neurovascular bundles were located superficial to the aponeurosis in this location. In conclusion, we found that a straight cannula needs to be navigated around an approximate 125-degree angle during performance of the EGR procedure. We think that this information provides evidence of potentially unrecognized complications of this procedure and leads to future investigations demonstrating anatomic and procedural outcomes.

Análise dos resultados do tratamento cirúrgico utilizando o retalho sural / Analysis of the results of surgical treatment using the sural flap

RESUMO Introdução: Fraturas complexas e extensas lesões de pele estão cada vez mais comuns devido aos traumas de alta energia. Uma alternativa para o tratamento dessas lesões nos membros inferiores é a utilização do retalho sural. Métodos: Esse foi um estudo retrospectivo, analítico-descritivo de análise exploratória documental de pacientes submetidos ao retalho sural em um hospital de referência em trauma do norte de Santa Catarina, Brasil. Foram analisados a idade, sexo, lateralidade, causa, local e tamanho da lesão, uso de tunelização e enxerto de pele, complicações e seus fatores de risco, além do manejo de tais complicações. Resultados: A amostra do estudo foi composta por 16 pacientes, com média de idade de 44,4 anos, 87,5% eram do sexo masculino. A causa da lesão mais prevalente foi trauma (75,0%) e o local da lesão foi mais prevalente na tíbia distal (43,8%). Em 50,0% dos casos os fatores de risco para as complicações estavam presentes, sendo que pacientes com diabetes mellitus e tabagistas exibiram 5 vezes mais chances de apresentar tais complicações. Necrose parcial teve uma prevalência de 25,0%, sendo que em 18,8% foi realizado apenas debridamento e em 6,3% enxertia. Conclusão: O retalho sural é uma boa alternativa para a cobertura de lesões dos membros inferiores devido ao bom índice de sucesso, mas não está livre de complicações. Tais complicações são mais prevalentes em pacientes que possuem fatores de risco como o tabagismo e diabetes mellitus.

ABSTRACT Introduction: Complex fractures and extensive skin lesions are increasingly common due to high-energy traumas. An alternative for treating these lesions in the lower limbs is the use of the sural flap. Methods: This was a retrospective, analytical-descriptive study of exploratory documental analysis of patients submitted to the sural flap in a trauma reference hospital in northern Santa Catarina, Brazil. Age, sex, laterality, cause, place, and size of the lesion, use of tunneling and skin grafting, complications and their risk factors, and the management of such complications were analyzed. Results: The study sample consisted of 16 patients with a mean age of 44.4 years; 87.5% were male. The cause of the most prevalent lesion was trauma (75.0%), and the site of the lesion was more prevalent in the distal tibia (43.8%). In 50.0% of the cases, risk factors for complications were present, and patients with diabetes mellitus and smokers were five times more likely to present such complications. Partial necrosis had a prevalence of 25.0%, and in 18.8%, only debridement was performed, and 6.3% grafting was performed. Conclusion: The sural flap is a good alternative for covering lower limbs lesions due to its good success rate, but it is not free of complications. Such complications are more prevalent in patients who have risk factors such as smoking and diabetes mellitus.

Sensory Neuropathy in Parkinson Disease: Electrodiagnostic Evaluation.

The relationship between Parkinson Disease (PD) and peripheral neuropathy (PN) has gained attention in recent years. There is increasing evidence of a-synuclein deposition and pointing to a form of small fiber neuropathy intrinsic to PD, medium-large fiber PN is also a relatively frequent and potentially severe complication in advanced levodopa-treated PD, but degenerative factors and vitamin deficiency were related. Objective: To determine the neurophysiological characteristics of patients with PD and the clinical manifestations of suspected PN. Methods: We performed a cross-sectional study between January 2014 and December 2017, of 36 patients diagnosed with PD who were referred for electrodiagnostic studies (EDX) with suspected clinical PN. We performed electromyography of five muscle or more (brachial biceps, first dorsal interosseous, thumb abductor, anterior tibial, medial gastrocnemius and short finger extensor), and nerve conduction/velocity studies on fibular and tibial nerves (motor) sural and superficial fibular nerves (sensory) and median and ulnar, (both motor and sensory). Results: Twenty-one females (58.3%) with an average age of 69.6 years and fifteen males (41.7%) with an average age of 68.0 years who were submitted for EDX were included in this study. All had a tremor and the average evolution of PD was 5 years. Thirty-two patients were receiving oral levodopa treatment. EDX of twenty-two patients demonstrated neuropathy abnormalities, and in 90.9% of these patients, sensory neuropathy was confirmed. The most common nerve found to be compromised was the superficial fibular nerve (55.0%), followed by the sural (50.0%). Conclusions: Sensory neuropathy was the main finding. Diagnosing PN based on symptom prevalence assessed by checklists and questionnaire has a risk of overestimating the prevalence of PN. The age and the time of disease evolution were factors related to neuropathy. In our study we found that 39% of the patients did not have neuropathic alterations despite clinical suspicion, which opens up new questions about the mechanisms of PD neuropathy and the possibility of fine fiber neuropathy in these patients, motivating further research.

Lower Limb Reconstruction - Fasciocutaneous Sural Flap.

Objective The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Methods A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Results Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from 6 to 75 years old. Most of the patients evolved with total healing of the flap ( n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered. Conclusion It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Cobertura de lesões em pé e terço inferior da perna com retalho fasciocutâneo reverso da panturrilha (Carriquiry) / Coverage of the lower third of the limb and foot injuries using reverse sural fasciocutaneous flap described by Carriquiry

Introdução: Lesões no terço distal dos membros inferiores, com exposição de ossos, articulações, tendões e vasos sanguíneos, não são passíveis do uso de enxertos de pele. Isto ocorre porque o leito vascular é exíguo e pela pobre granulação das feridas, podendo apenas ser corrigidas com retalhos musculares, miocutâneos, fasciocutâneos ou transferência microcirúrgica. Métodos: O retalho em seu limite inferior é demarcado a partir de 5 cm acima dos maléolos. Superiormente, é marcado num comprimento suficiente para cobertura total da lesão. Realizada incisão em demarcação prévia, e elevados pele e tecido subcutâneo juntamente com a fáscia muscular. O nervo sural é preservado em seu leito original. A elevação do retalho se dá até o ponto inferior marcado (o pedículo). Neste ponto, o retalho é transposto numa angulação suficiente para alcançar a lesão. Resultados: Oito casos foram operados utilizando o retalho descrito. Todos apresentavam exposição de ossos e tendões em região distal da perna, dorso do pé ou ambos, nos quais foram utilizados o retalho fasciocutâneo reverso da perna com a técnica proposta por Carriquiry. Os casos apresentaram resultados estético e funcional satisfatórios. Conclusão: O retalho utilizado se presta à correção de lesões do terço inferior da perna e do pé. É relativamente fácil de ser confeccionado, com bom suprimento vascular, e não há perda funcional do leito doador.

Introduction: Skin grafts are not effective to cover lesions in the distal third of the lower limbs that expose the bones, joints, tendons, and blood vessels due to a limited vascular bed and poor granulation of the wounds. These lesions can only be corrected with microsurgical transfer or muscle, myocutaneous, or fasciocutaneous flaps. Methods: The lower border of the flap was marked 5 cm above the malleolus. The upper border was marked after providing sufficient length for complete coverage of the lesion. The incision was performed at the marked upper border, and the skin and subcutaneous tissue were elevated together with muscle fascia. The sural nerve was preserved in its original bed. The flap was lifted to the marked lower border (the pedicle). At this point, the flap was transposed at a sufficient angle to cover the lesion. Results: Eight cases of surgery were conducted using the flap described above. All cases had exposed bones and tendons in the distal region of the limb, back of the foot, or both, in which the reverse sural fasciocutaneous flap with the technique proposed by Carriquiry was used. The cases showed satisfactory esthetic and functional results. Conclusion: The used flap can correct lesions of the lower third of the limbs and foot. It is relatively easy to make, with good vascular supply, and there is no functional loss of the donor area.

Lower Limb Reconstruction - Fasciocutaneous Sural Flap / Reconstrução de membro inferior- retalho fasciocutâneo sural

Abstract Objective The present study aims to evaluate the use of the reverse-flow sural fasciocutaneous flap to cover lesions in the distal third of the lower limb. Methods A total of 24 cases were analyzed, including 20 traumatic injuries, 3 sports injuries, and 1 case of tumor resection. Results Among the 24 evaluated medical records, 16 patients were male, and 8 were female. Their age ranged from6 to 75 years old. Most of the patients evolved with total healing of the flap (n= 21). There was only one case of total necrosis of the flap in an insulin-dependent diabetic, high blood pressure patient, evolving to subsequent limb amputation. In two cases, there was partial necrosis and subsequent healing by secondary intention; one of these patients was a heavy smoker. Complications were associated with comorbidities and, unlike other studies, no correlation was observed with the learning curve. There was also no correlation with the site or size of the lesion to be covered. Conclusion It is clinically relevant that the success rate of the reverse-flow sural fasciocutaneous flap technique was of 87.5%. This is a viable and effective alternative in the therapeutic arsenal for complex lower limb lesions.

Resumo Objetivo Avaliar o uso do retalho fasciocutâneo sural de fluxo reverso na cobertura de lesões no terço distal dos membros inferiores. Métodos Foram analisados 24 casos, 20 de origem traumática, três por lesões esportivas e um por ressecção de lesão tumoral. Resultados Dos 24 prontuários avaliados, 16 eram homens e oito mulheres. A idade variou de seis a 75 anos. A maioria dos pacientes evoluiu com cicatrização total do retalho (21). Houve apenas um caso de necrose total do retalho em paciente diabético insulinodependente e hipertenso, evoluiu para posterior amputação do membro. Em dois casos, houve necrose parcial composterior cicatrização por segunda intenção, um desses pacientes era tabagista pesado. As complicações foram associadas às comorbidades e, ao contrário do evidenciado por outros estudos, não houve correlação com a curva de aprendizado. Também não houve correlação com o local ou o tamanho da lesão a ser coberta. Conclusão Tem-se como relevância clinica que a técnica de retalho fasciocutâneo sural de fluxo reverso usada obteve 87,5% de sucesso, é uma opção viável e eficaz no arsenal terapêutico das lesões complexas dos membros inferiores.

A possible role of endoneurial fibroblast-like cells in the resolution of endoneurial oedema following nerve crush injury / El posible rol de los fibroblastos endoneurales en la resolución del edema endoneural después de una lesión por aplastamiento nervioso

SUMMARY: Endoneurial oedema is a salient feature of all types of neuropathy. Its elimination is crucial during the complications of nerve recovery. The objective was to study a possible role of the endoneurial fibroblasts in the resolution of nerve edema. Forty-two albino male rats aged between 30 and 40 days (weight 200 g to 250 g) were used in this study. The left sural nerves of 36 rats were subjected to crush injury at one to three-week intervals with six animals per interval. The right and left sural nerves of the remaining six rats were used as controls. At the end of the second week after crush injury, the endoneurium showed channel-like spaces that were lined by fibroblast-like cells and collagen bundles that contained degenerated myelin, and were connected to the subperineurial spaces. Flattened fibroblast-like cells were arranged in several layers in the subperineurial, forming barrier-like cellular sheets localizing to the endoneurial oedema in the space. Fibroblast-like cells also wrapped around the regenerating nerve fibres with their branching cytoplasmic processes. During the third week, the flattened fibroblast-like cells formed nearly continuous cellular sheets in the subperineurial spaces. Macrophages were frequently observed between these cellular barrier-like sheets and in the subperineurial. The endoneurial fibroblast-like cells form barrier-like cellular sheets that probably localise the endoneurial oedema in the subperineurial space. It also appear to create endoneurial channel-like spaces containing degenerated myelin and endoneurial oedema, which may be helpful in localizing and resolving such oedema.

RESUMEN: El edema endoneural es una característica destacada de todos los tipos de neuropatía. Su eliminación es importante durante las complicaciones de la recuperación nerviosa. El objetivo fue estudiar un posible papel de los fibroblastos endoneurales en la resolución del edema nervioso. En este estudio se utilizaron 42 ratas macho albinas con edades entre los 30 y 40 días (peso 200 a 250 g). Los nervios surales izquierdos de 36 ratas se sometieron a lesiones por aplastamiento en intervalos de una a tres semanas con seis animales por intervalo. Se usaron los nervios surales derecho e izquierdo de las seis ratas restantes como controles. Al final de la segunda semana después de la lesión por aplastamiento, el endoneuro mostró espacios en forma de canal que estaban revestidos por células similares a fibroblastos y haces de colágeno que contenían mielina degenerada y se conectaron a los espacios subperineurales. Las células aplanadas de fibroblastos se dispusieron en varias capas en el subperineuro, formando láminas celulares de tipo barrera que se localizaban en el espacio del edema endoneural. Las células similares a fibroblastos también envolvían las fibras nerviosas regeneradoras con sus procesos citoplásmicos ramificados. Durante la tercera semana, las células aplanadas de fibroblastos formaron láminas celulares casi continuas en los espacios subperineurales. Los macrófagos se observaron con frecuencia entre estas láminas similares a barreras celulares y en el subperineuro. Las células de tipo fibroblasto endoneural formaban láminas celulares de tipo barrera que probablemente localizan el edema endoneural en el espacio subperineural. También parece que crea espacios en forma de canal endoneural que contienen mielina degenerada y edema endoneural, que pueden ser útiles para localizar y resolver este edema.

Caso Clínico: Cirugía Reconstructiva de Tobillo / Case Report: Reconstructive Ankle Surgery

INTRODUCCIÓN: La diabetes mellitus es un importante problema de salud pública, según la Organización Mundial de la Salud, 422 millones de adultos en todo el mundo en 2014. En 2012 provocó 1.5 millones de muertes a nivel mundial; es la primera causa de amputación no traumática en miembros inferiores y las infecciones del pie ocurren con alta frecuencia en pacientes mal controlados. Este caso muestra la reconstrucción de defectos de partes blandas en el tercio inferior pierna, talón, maléolos y pie a través de la descripción del colgajo sural reverso. En este estudio se discuten las ventajas y desventajas de la utilización de esta técnica. CASO CLÍNICO: Paciente de sexo femenino 56 años de edad con antecedentes de Diabetes Mellitus tipo 2 mal controlada, que sufrió una fractura de tobillo izquierdo tratada con osteosíntesis; durante el postoperatorio acudió a emergencia, por presentar dolor de gran intensidad en tobillo izquierdo, fiebre, dehiscencia de herida quirúrgica, acompañada de secreción serosa. EVOLUCIÓN: La paciente luego de varias limpiezas quirúrgicas y cambios de terapia de cierre asistido por presión negativa, se consigue controlar la infección, con persistencia del defecto de cobertura ósea y del material de osteosíntesis. Se presentaron complicaciones adicionales como la rigidez articular, atrofia muscular; se decidió realizar reconstrucción del tercio distal del pie usando colgajo fasciocutáneo sural de flujo reverso, que evolucionó satisfactoriamente, consiguiendo cubrir el defecto con tejido biológico. CONCLUSIÓN: El colgajo sural de flujo reverso, es una técnica reproducible, que permite cubrir defectos de cobertura en tercio distal de pierna y tobillo; acortar los tiempos de hospitalización, especialmente cuando hay exposición ósea o de material de osteosíntesis.

BACKGROUND: Diabetes mellitus is a major public health problem, according to the World Health Organization, 422 million adults worldwide in 2014. In 2012, it caused 1.5 million deaths worldwide. Diabetes is the leading cause of non-traumatic amputation in lower limbs and foot infections occur with high frequency in poorly controlled patients. This case shows the reconstruction of soft tissue defects in the lower third leg, heel, malleoli and foot through the description of the reverse sural flap. In this study the advantages and disadvantages of the use of this technique are discussed. CASE REPORT: A 56-year-old female patient with a poorly controlled history of Diabetes Mellitus type 2, who suffered a fracture of the left ankle treated with osteosynthesis, and who during the postoperative period attended emergency orthopedics and traumatology, due to severe pain in the left ankle, fever, dehiscence of surgical wound, accompanied by serous secretion. EVOLUTION: The patient, after several surgical cleanings and changes in closure therapy assisted by negative pressure, manages to control the infection, with persistence of the bone coverage defect and the osteosynthesis material. There were additional complications such as joint stiffness, muscle atrophy; it was decided to reconstruct the distal third of the foot using a reverse flow sural fasciocutaneous flap, which evolved satisfactorily, managing to cover the defect with biological tissue. CONCLUSIONS: The sural flap of reverse flow is a reproducible technique that allows to cover coverage defects in the distal third of the leg and ankle; shorten hospitalization times, especially when there is bone exposure or osteosynthesis material.

Endoscopic Sural Nerve Removal in Obstetric Brachial Plexopathy Using Basic Endoscopy Instruments: Technical Note

Introduction The sural nerve (SN) is commonly used for grafting following resection of a neuroma-in-continuity in neonatal brachial plexus lesions (NBPL). The main drawbacks of the current open techniques are large scars and contractures in the late postoperative stage, which may, in severe cases, cause equinovarus contractures. Objective To describe the feasibility and the technical aspects of endoscopic SN harvesting with the use of basic endoscopy instruments and small incisions. Methods Prospective observational study of NBPL subjected to endoscopic nerve harvesting between February of 2012 and February of 2014 in a consecutive series. Patients were operated at the Felício Rocho Hospital (Hospital Felício Rocho) and the Clinical Hospital, Federal University of Minas Gerais (Hospital das Clínicas UFMG), Belo Horizonte/MG, in Brazil. The study outcomes assessed were: scar size, presence or absence of contractures in the calf, bleeding volume (measured by the number of gauzes used) and number of incisions. Only patients with a follow-up longer than 6 months were included. Results Seven patients were selected and twelve endoscopic nerves were endoscopically harvested. The average surgery time was 45 minutes. Nine SNs were harvested through two incisions, and three nerves through three incisions. The estimated bleeding was less than 5ml and there were no complications or contractures during the follow-up period of 6 months to 4 years. Conclusion Sural nerve harvesting in children with NBPL is feasible and it offers the advantage of needing only two or three small incisions using basic endoscopy instruments.

Introdução O nervo sural é a melhor opção para enxertia nas reconstruções microcirúrgicas da plexopatia braquial obstétrica. O método clássico aberto com incisão longitudinal desde o tornozelo até a fossa poplítea ou em incisões em degraus possuem as desvantagens de cicatrizes amplas e contraturas em equinovarus (pé torto). Atualmente, o emprego de endoscópios específicos para a retirada de enxertia de nervos e vasos mostra resultados satisfatórios em relação ao encurtamento do tempo cirúrgico e à redução no tamanho das incisões, mas tem como inconveniente o alto custo de aquisição e manutenção. Objetivo Discutir a viabilidade e descrever nota técnica da retirada do nervo sural utilizando instrumental básico de endoscopia e pequenas incisões. Métodos Estudo observacional prospectivo em pacientes com plexopatia braquial obstétrica submetidos a retirada do nervo sural por endoscopia no período de fevereiro de 2012 a fevereiro de 2014 no Hospital Felicio Rocho e no Hospital das Clinicas UFMG, Belo Horizonte/MG, Brasil. Resultados Sete pacientes foram selecionados e foram retirados doze nervos surais por endoscopia. O tempo médio da cirurgia foi de 45 minutos. Nove nervos surais foram retirados por duas incisões, e três nervos foram retirados por três incisões. O sangramento foi inferior a 5ml e não houve complicações no pós-operatório imediato e tardio em acompanhamento entre 6 meses e 4 anos. Não foram observadas contraturas no período observacional. Conclusão O nervo sural pode ser retirado utilizando duas ou três pequenas incisões por meio de instrumental endoscópico básico em crianças com plexopatia braquial obstétrica.

Anatomy of the sural nerve related to calcaneal tendon, intermalleolar line and small saphenous vein / Anatomía del nervio sural en relación con el tendón calcáneo, la línea intermaleolar y la vena safena parva

Sural nerve (SN) courses from the posterior aspect of leg to the lateral side of ankle and foot. Anatomy of the SN is of clinical importance due to its involvement in nerve biopsy, nerve graft harvesting including injuries during calcaneal tendon repair. Despite substantial knowledge in the literature, more easily located landmarks and data regarding the symmetry are still needed. Ninety-eight lower extremities from 31 males and 18 females were dissected in this study. The SN originated from the union between the medial and lateral sural cutaneous nerves in 52.0 % of the legs. The distance from the union point to the intermalleolar line (IML) was 16.3±8.4 (SD) cm. The ratio of this distance to the fibular length (apex of head to lateral malleolus or LM) was 0.47±0.23 cm. In 84.7 % of the legs, the SN initially coursed medial to and then crossed the lateral border of calcaneal tendon at the distance of 8.4±2.1 cm above the IML. The ratio to the fibular length was 0.25±0.06 cm. At the level of IML, the SN was posterior to the most prominent part of the LM in 95.9 % of the legs with the distance of 2.6±0.5 cm. At the closest point, the SN was lateral to the small saphenous vein in 74.5 % of the legs and the distance from this point to the IML was 10.6±4.7 cm. The ratio to the fibular length was 0.31±0.14 cm. Side difference or asymmetry was observed in a substantial number of specimens. These data are crucial for not only localizing the SN during biopsy and graft harvesting but also avoiding the nerve injury during relevant surgical procedures.

El nervio sural (NS) transcurre por la región posterior de la pierna, el tobillo y el pie. La anatomía del NS es de importancia clínica durante la realización de una biopsia, el desarrollo de injerto de nervio, incluyendo lesiones del nervio durante la reparación del tendón calcáneo. A pesar del conocimiento sustancial en la literatura, aún se necesitan puntos de referencia más fáciles de localizar e información sobre la simetría. Noventa y ocho miembros inferiores de 31 hombres y 18 mujeres fueron disecados. El NS se originó a partir de la unión entre los nervios cutáneo sural medial y cutáneo sural lateral en el 52,0 % de las piernas. La distancia desde el punto de unión a la línea intermaleolar (IML) fue de 16,3±8,4 (SD) cm. La relación de esta distancia a la longitud de la fíbula (vértice de la cabeza al maléolo lateral o LM) fue de 0,47±0,23 cm. En el 84,7 % de las piernas, el NS se ubicó inicialmente medial y luego cruzó el margen lateral del tendón calcáneo a una distancia de 8,4±2,1 cm proximal a la IML. La relación de longitud de la fíbula fue de 0,25±0,06 cm. A nivel de la IML, el NS se localizaba posterior a la parte más prominente de la LM en el 95,9 % de las piernas, con una distancia de 2,6±0,5 cm. En el punto más cercano, el NS se localizaba lateral a la vena safena parva en 74,5 % de las piernas y la distancia desde este punto hasta la IML fue de 10,6±4,7 cm. La relación de longitud de la fíbula fue 0,31±0,14 cm. La diferencia entre los lados o asimetría se observó en un número considerable de ejemplares. Estos datos son esenciales no sólo para localizar el NS durante la biopsia y la realización del injerto sino también para evitar la lesión del nervio durante procedimientos quirúrgicos relevantes.

Hind limb sensory innervation in rats: comparison between sural and saphenous nerve morphometry / Inervación sensorial de los miembros posteriores en ratas: comparación morfométrica entre los nervios sural y safeno

Although numerous studies investigate sensory recovery of the hind paw of the rat after nerve damage, still no comprehensive overview of its normal innervation is present in the literature. We investigated the morphometry of myelinated fibers in the sural and saphenous nerves and analyzed their size distributions in young rats. Six 30-day-old female Wistar rats were perfused with 2.5% glutaraldehyde and their right and left sural and saphenous nerves were prepared for light microscopy and morphometry. Morphometric data were compared between segments (proximal versus distal) and sides (right versus left) for the same nerves. Also, segments from right or left sides were compared between nerves (sural versus saphenous). Both, the sural and saphenous nerves, exhibited proximal to distal symmetry on both sides as well as left-right symmetry. Histograms of the diameter of the myelinated fibers were unimodal in both nerves, regardless of segments or sides with the peaks of the fibers size occurring between 2.5 and 4.0 µm. The axon distributions reflected the myelinated fiber distributions, with the sural and saphenous nerves peaking between 1.5 and 2.0 µm. The G ratio (the ratio between the axon and fiber diameters) distributions were also unimodal, with peaks at 0.6 for both nerves. This study contributes to the literature with information on the myelinated fibers morphometry from the two sensory nerves responsible for the rat hind limb innervation. This information is valuable for a better understanding of the possible contribution of collateral sprouting from the sural or saphenous nerves on the paw sensory territory recovery observed after one of these nerves is damaged.

Aunque numerosos estudios investigan la recuperación sensorial del miembro pélvico o posterior de la rata después del daño en los nervios, aún no existe en la literatura una visión global de su inervación normal. Investigamos la morfometría de fibras mielínicas de los nervios sural y safeno y analizamos sus distribuciones de tamaño en ratas jóvenes. Seis ratas Wistar de 30 días de edad fueron perfundidas con 2,5% de glutaraldehído, se prepararon los nervios sural y safeno derecho e izquierdo para microscopía de luz y morfometría. Datos morfométricos fueron comparados entre los segmentos (proximal vs distal) y laterales (derecho vs izquierdo) para los mismos nervios. Además, los segmentos de los lados derecho e izquierdo se compararon entre los nervios (sural vs safeno). Ambos nervios sural y safeno exhibieron una simetría proximal a distal en ambos lados, así como una simetría izquierda-derecha. Histogramas del diámetro de las fibras mielinizadas eran unimodales en ambos nervios, independientemente de los segmentos o de los lados, siendo los peaks del tamaño de las fibras entre 2,5 y 4,0 micras. Las distribuciones de los axones reflejan las distribuciones de fibras mielinizadas, de los nervios sural y safeno que alcanzaban entre 1,5 and 2,0 µm. La relación de G (relación entre los diámetros de los axones y de fibra) eran también unimodales, alcanzando 0,6 para ambos nervios. Este estudio contribuye a la literatura con los datos de la morfometría de fibras mielinizadas de ambos nervios sensoriales responsables de la inervación de la extremidad pélvica de la rata. Esta información es valiosa para una mejor comprensión de los nervios sural y safeno en la recuperación sensorial del miembro después de que uno de estos nervios ha sido dañado.

Correction of iatrogenic injury of the obturator nerve during pelvic laparoscopic lymphadenectomy by the use of sural nerve grafts.

•Intraoperative injury of the obturator nerve is not an infrequent complication of gynecological surgeries.•This injury can occur in association with pelvic lymphadenectomy for uterine or cervical cancer.•This manuscript demonstrates an alternative technique for the obturator nerve repair, when primary end to end anastomosis is not possible.