Davide Ciclamini

Update on nerve repair by biological tubulization

Many surgical techniques are available for bridging peripheral nerve defects. Autologous nerve grafts are the current gold standard for most clinical conditions. In selected cases, alternative types of conduits can be used. Although most efforts are today directed towards the development of artificial synthetic nerve guides, the use of non-nervous autologous tissue-based conduits (biological tubulization) can still be considered a valuable alternative to nerve autografts. In this paper we will overview the advancements in biological tubulization of nerve defects, with either mono-component or multiple-component autotransplants, with a special focus on the use of a vein segment filled with skeletal muscle fibers, a technique that has been widely investigated in our laboratory and that has already been successfully introduced in the clinical practice.

Clinical Applications of End-to-Side Neurorrhaphy: An Update

End-to-side neurorrhaphy constitutes an interesting option to regain nerve function after damage in selected cases, in which conventional techniques are not feasible. In the last twenty years, many experimental and clinical studies have been conducted in order to understand the biological mechanisms and to test the effectiveness of this technique, with contrasting results. In this updated review, we consider the state of the art about end-to-side coaptation, focusing on all the current clinical applications, such as sensory and mixed nerve repair, treatment of facial palsy, and brachial plexus injuries and painful neuromas management.

Replantation: Current Concepts and Outcomes

Techniques to improve the chance of successful replantation of digits are well established. Indications and contraindications for replantation are generally agreed on, but they continue to evolve as excellent outcomes are achieved at centers with experience and expertise. Form and function can be restored with avulsion injuries and distal amputations, with good results and high patient satisfaction. Increased financial pressure to control the costs of health care and increased accountability for evidence-based outcomes may lead to the regionalization of replantation care and shared decision making in recommending replantation or revision amputation.

Functional and subjective results of 20 thumb replantations

The aim of this retrospective study was to analyse the results of 20 thumb replantations with special and exhaustive attention on functional outcomes. Twenty patients with traumatic thumb amputation were enrolled in the study. Range of motion, grip strength, sensory recovery, and subjective perception of overall hand function recovery were measured. The average age at the time of surgery was 35 years (range, 13-73 years). The mean follow-up was 3.25 years (range, 1.9-10.25 years). The long-term results of thumb replantation confirmed satisfactory outcomes in terms of general upper limb function, handgrip and pinch strength, and social and work reintegration. Sensory recovery remained unsatisfactory despite the fact that we did not need to perform any kind of revision surgery as a consequence of inadequate thumb sensibility. For the first time in the existing literature, no functional parameter that contributes to the assessment of the function of replanted thumbs has been excluded. We resume in the same study the analysis of all functional parameters that are useful to define results of thumb replantation.

Peripheral Nerve Defects: Overviews of Practice in Europe

Many surgical techniques are available for the repair of peripheral nerve defects. Autologous nerve grafts are the gold standard for most clinical conditions. In selected cases, alternative types of reconstructions are performed to fill the nerve gap. Non-nervous autologous tissue-based conduits or synthetic ones are alternatives to nerve autografts. Allografts represent another new field of interest. Decision making in the treatment of nerve defects is based on timing of referral, level of the injury, type of lesion, and size of any gap. This review focuses on current clinical practice, influenced by the numerous new experimental researches.

Acute Compartment Syndrome of the Arm after Minor Trauma in a Patient with Optimal Range of Oral Anticoagulant Therapy: A Case Report

Compartment syndrome of the arm is a rare event that can be subsequent to trauma or other pathological and physical conditions. At the arm the thin and elastic fascia may allow accumulation of blood more than in other districts, especially in patients undergoing anticoagulant therapy. We describe a rare case of an acute compartment syndrome of the arm after minor trauma with partial biceps brachii rupture in a patient with warfarin therapy and optimal value of INR. Prompt diagnosis and surgical decompression helped to avoid the occurrence of complications with a satisfying recovery of arm function.

Reconstruction of traumatic losses of substance at the elbow

Traumatic lesions at the elbow involving great loss of substance are uncommon, but represent a significant problem when such cases are referred to a trauma department. Most of these injuries may cause severe final functional impairment, thereby jeopardising future activities, particularly in cases where treatment was delayed or inappropriate. The timing and method of treatment are critical. The trauma may involve soft tissues only, or bone and joint, or several structures at the same time, which results in combined complex tissue defects. Each type of tissue loss should be managed by choosing the most suitable technique from the armamentarium of reconstructive surgery, taking into account different priorities and the optimum timing (immediate or delayed, one- or two-stages). The authors describe a spectrum of indications and techniques that can be useful tools in managing these injuries.

Compound or Specially Designed Flaps in the Lower Extremities

Novel and combined tissue transfers from the lower extremity provide new tools to combat soft tissue defects of the hand, foot, and ankle, or fracture nonunion. Flaps can be designed for special purposes, such as providing a gliding bed for a grafted or repaired tendon or for thumb or finger reconstruction. Propeller flaps can cover soft tissue defects of the leg and foot. In repairing severe bone and soft tissue defects of the lower extremity, combined approaches, including external fixators, one-stage vascularized bone grafting, and skin or muscle flap coverage of the traumatized leg and foot, have become popular.

Ultrasound-Guided Pulse-Dose Radiofrequency: Treatment of Neuropathic Pain after Brachial Plexus Lesion and Arm Revascularization

Neuropathic pain following brachial plexus injury is a severe sequela that is difficult to treat. Pulsed radiofrequency (PRF) has been proved to reduce neuropathic pain after nerve injury, even though the underlying mechanism remains unclear. This case report describes the use of ultrasound-guided PRF to reduce neuropathic pain in a double-level upper extremity nerve injury. A 25-year-old man who sustained a complete left brachial plexus injury with cervical root avulsion came to our attention. Since 2007 the patient has suffered from neuropathic pain (NP) involving the ulnar side of the forearm, the proximal third of the forearm, and the thumb. No pain relief was obtained by means of surgery, rehabilitation, and medications. Ultrasound-guided PRF was performed on the ulnar nerve at the elbow level. The median nerve received a PRF treatment at wrist level. After the treatment, the patient reported a consistent reduction of pain in his hand. We measured a 70% reduction of pain on the VAS scale. PRF treatment allowed our patient to return to work after a period of absence enforced by severe pain. This case showed that PRF is a useful tool when pharmacological therapy is inadequate for pain control in posttraumatic neuropathic pain.

Lower Limb Core Scale: A New Application to Evaluate and Compare the Outcomes of Bone and Soft-Tissue Tumours Resection and Reconstruction

Several methods are used to evaluate the functional outcome of tumour resections and reconstructions in the lower limb. However, one of their most common limitations is that they are specifically developed to evaluate only oncological patients. We introduced the Lower Limb Core Scale (LLCS) to overcome this limitation. The aim of this study was to evaluate the functional and subjective results in the lower limb and to evaluate the use of the LLCS. We conducted a retrospective cohort study using various tools to investigate the outcomes. The results of the LLCS were correlated with the results of other functional tests. A total of 44 patients were included in the study. None of the demographic variables correlated with the functional or health-related quality of life (QoL) scores except for gender, whereby male patients had an increased functional score. The correlation between LLCS and other scores was positive (r 2 = 0.77). The satisfactory QoL scores, and functional outcomes scores indicated the LLCS to be a reliable option for general and specific evaluation of lower limb reconstructions. We suggest using the LLCS for comparisons of oncological reconstructions with lower limb reconstructions in different disciplines.