Gedge D. Rosson

Wound healing in denervated tissue

Sacral and trochanteric pressure sores in patients with plegias, and foot ulceration in patients with diabetic neuropathy, are similar because these wounds occur in tissues that do not have normal innervation. While it is recognized that insensitive tissue increases the likelihood of ulceration and recurrence of ulceration, this review attempts to answer the question, Is wound healing impaired in denervated tissue? A review of the scientific literature of the past 35 years demonstrates that all phases of wound healing are impaired in denervated tissue, and these mechanisms are different from those related to one of the underlying diseases, diabetes. Understanding the value of innervation, a goal of wound healing should be to seek strategies that provide reinnervation to these at-risk tissues.

Multilevel analysis of the impact of community vs patient factors on access to immediate breast reconstruction following mastectomy in Maryland.

OBJECTIVE To determine whether various individual factors such as patient demographics and various community factors such as characteristics of the neighborhood in which the patient lives would influence access to immediate breast reconstruction. DESIGN Multilevel analysis of the Maryland Hospital Discharge Database, a prospectively collected observational database of inpatient care for all hospitals in Maryland. SETTING Database analysis. PATIENTS We queried for International Classification of Diseases, Ninth Revision procedure codes for all patients undergoing mastectomy and reconstruction during the same hospitalization in Maryland from January 1, 1995, through December 31, 2004. MAIN OUTCOME MEASURES Disparities in immediate reconstruction rates via analysis of the impact of patient-level and community-level factors. RESULTS A total of 18 690 patients underwent mastectomy in Maryland during the study period, 27.9% of whom had immediate reconstruction. On multivariate analysis, patient factors such as African American race/ethnicity and older age had a negative association. Community factors such as increasing household income, increasing population density, and increasing proportion of the community with at least some college education had a positive association, while increasing home value and increasing African American composition of the patients neighborhood had a negative association. The impacts of ethnic/racial mix and educational level of the patients neighborhood were independent of the patients race/ethnicity. CONCLUSIONS Community factors beyond patient characteristics have a significant association with immediate reconstruction. Prospective community-level public health policy measures should be developed to address these inequalities (particularly racial/ethnic disparities based on neighborhood) and to increase the likelihood of obtaining immediate reconstruction.

The emerging role of antineoplastic agents in the treatment of keloids and hypertrophic scars: a review.

The management of keloids and hypertrophic scars continues to challenge health-care providers. Though both forms of pathologic scarring are distinct entities at the macro and microscopic level, their etiologies and treatment are often similar. Potential treatment approaches are progressing, and combinations of treatment options have been proposed in the literature with promising outcomes. The treatment evolution has reached a level where molecular therapeutic modalities are being investigated. Currently, no gold standard treatment exists. Overall success rates and patient satisfaction seem to be slowly climbing, but additional investigational studies must continue to be performed. Several studies have investigated antineoplastic agents, and there seems to be a marked improvement in rates of recurrence, patient satisfaction, and overall quality of scar when these agents are used. Intralesional injection and/or wound irrigation with interferon-a2b, interferon-g, mitomycin-C, bleomycin, or 5-fluorouracil seems to have a positive effect on the reduction of pathologic scars. There is mounting evidence that these drugs used alone or in combination therapy, have the potential to be an integral part of the treatment paradigm for hypertrophic scars and keloids.

Tibial nerve decompression in patients with tarsal tunnel syndrome: pressures in the tarsal, medial plantar, and lateral plantar tunnels.

Background: The anatomical basis for the surgical techniques used to treat tarsal tunnel syndrome is not well studied. The authors sought to evaluate their hypotheses that (1) pronation and pronation with plantar flexion of the intact foot would have higher pressures than the intact foot in other positions; (2) decompression surgery would significantly lower the pressure in all three tunnels in all foot positions, and roof incision plus septum excision would lower the pressure further in some positions; and (3) the pressures in symptomatic patients would be significantly higher than those in an analogous cadaver study. Methods: In 10 patients with tarsal tunnel syndrome, the authors intraoperatively measured pressures in the tarsal, medial plantar, and lateral plantar tunnels in multiple foot positions before and after excision of the tunnel roofs and intertunnel septum. Results: The authors found that (1) pronation and plantar flexion significantly increased pressures in the medial and lateral plantar tunnels, to levels sufficient to cause chronic nerve compression; (2) tunnel release and septum excision significantly decreased those pressures; and (3) compared with cadaver pressures, patients had similar tarsal tunnel pressures but higher lateral plantar tunnel pressures in some positions. Conclusions: Many surgeons operating on patients with tarsal tunnel syndrome do not decompress the respective medial plantar and lateral plantar nerves and excise the septum. The authors’ study validates the hypotheses that patients who are clinically suspected of having chronic compression of the tibial nerve and its branches at the ankle have higher tunnel pressures and that releasing these structures decreases the pressures.

Superficial peroneal nerve anatomic variability changes surgical technique.

Entrapment of the superficial peroneal nerve is an uncommon entrapment that occurs in sports trauma or fracture and dislocation as the nerve comes under pressure between the underlying muscles and the overlying fascia. Although the superficial peroneal nerve traditionally is depicted as being in the lateral compartment, we have found it in the anterior compartment in some patients. We hypothesized that patients with entrapment of the superficial peroneal nerve were more likely to have this anatomic variant than the normal population and that surgical decompression of both compartments would improve clinical outcome versus the historic surgical approach of decompressing just the lateral compartment. We retrospectively reviewed the location of the superficial peroneal nerve in a consecutive series of 35 limbs in 31 patients with entrapment of the superficial peroneal nerve. The results showed that the location of the superficial peroneal nerve was not different from the reported normal variation. However, the location of the superficial peroneal nerve in the anterior compartment in 47% of the patients in this series suggests that surgeons must explore the anterior and the lateral compartments in each patient with entrapment or neuroma of the superficial peroneal nerve. Level of Evidence: Therapeutic study, Level IV (case series—no, or historical, control group). See the Guidelines for Authors for a complete description of levels of evidence.

Facial palsy: Anatomy, etiology, grading, and surgical treatment

The modern microvascular reconstructive surgeon has quite an arsenal when managing the paralyzed face and injury to the facial nerve. After a brief description of the anatomy, etiology, facial nerve syndromes, and grading schemes, we detail our approach to the patient with facial paralysis. In reviewing our methods, we discuss the organ-based timing protocol, along with recent advancements in surgical technique.

Anatomic site for proximal tibial nerve compression: a cadaver study.

Primary compression of the tibial nerve beneath the fibromuscular sling of the origin of the soleus muscle is rarely discussed in the literature. To evaluate the location and characteristics of the soleal fibromuscular sling and its relationship to the tibial nerve, 36 cadaver limbs were dissected. The leg length, location of soleal fibromuscular sling, presence of a thickened fibrous band at the soleal sling, and narrowing in the tibial nerve were recorded. The average leg length was 47.8 cm (SD ± 4.16). The fibromuscular soleal sling was 9.3 cm (SD ± 1.44) distal to the medial tibial plateau. Although 56% (20/36) of specimens had a fibrous band, only 8% (3/36) demonstrated a focal narrowing directly under this fascial sling. This study demonstrates that the fibromuscular sling of the soleus muscle may act as a potential compression site of the tibial nerve. These findings offer insight and potential hope for those patients who have persistent plantar numbness after tarsal tunnel decompression and for those patients with plantar numbness who also have weakness of toe flexion.

Abdominally based free flap planning in breast reconstruction with computed tomographic angiography: systematic review and meta-analysis.

Background: Computed tomographic angiography is often used for preoperative mapping. The authors aimed to systematically assess breast reconstruction outcomes after abdominally based free flaps planned with preoperative computed tomographic angiography versus Doppler ultrasonography. Methods: A search of the PubMed, EMBASE, and Scopus databases and an additional hand-search of relevant articles until June of 2012 rendered 442 English-language citations. Three authors independently reviewed these citations and included all the studies comparing preoperative computed tomographic angiography versus Doppler ultrasonography with regard to short-term postoperative outcomes and operative times. A meta-analysis was performed to evaluate the incidence of flap-related complications (seven studies), donor-site morbidity (four studies), and operative times (five studies) between preoperative computed tomographic angiography and Doppler ultrasonography. A pooled relative risk was calculated using a random-effect model to compare complication rates between the computed tomographic angiography and Doppler ultrasonography groups. Results: A total of 13 studies met inclusion criteria. Preoperative computed tomographic angiography was associated with significantly fewer flap-related complications (relative risk, 0.87; 95 percent CI, 0.78 to 0.97), reduced donor-site morbidity (relative risk, 0.84; 95 percent CI, 0.76 to 0.94), and shorter reconstruction operative time by 87.7 minutes (mean difference, 87.7 minutes; 95 percent CI, 78.3 to 97.1 minutes). Conclusions: The use of preoperative computed tomographic angiography reduces the operative time, postoperative flap-related complications, and donor-site morbidity compared with Doppler ultrasonography. Preoperative computed tomographic angiography has the potential to reduce operative cost and increase efficiency in the operating room. Thus, preoperative mapping by computed tomographic angiography should be strongly considered for abdominally based free flap breast reconstruction.

The Anterior Tibialis Artery Perforator (ATAP) Flap for Traumatic Knee and Patella Defects: Clinical Cases and Anatomic Study

Soft-tissue reconstruction of traumatic patella and proximal tibial defects is challenging. Pedicled perforator-based adipocutaneous rotation flaps are a versatile local option as they have axial perfusion and greater freedom of transposition compared with random-pattern flaps, and replace the ideal tissue properties of this anatomic region.Experimental: Anatomic dissections were performed on 15 fresh cadaver legs and location of the dominant perforator measured. Clinical: A retrospective review was conducted at the University of Maryland/R Adams Cowley Shock Trauma Center evaluating patients over a 3-year period.Experimental: Cadaver dissections confirmed a principal perforator at 11.4 ± 1.6 cm inferior to the patella. This vessel is consistently suitable in length and caliber for large rotation flap design. Clinical: Anterior tibial artery perforator flaps were performed on 4 patients following Gustilo IIIB wounds to the patella and tibial plateau. Two patients had rotation flap reconstructions to salvage failed gastrocnemius muscle flaps. All flaps were successful, however, one patient had overwhelming hardware infection several months later despite successfully healed flap.Local anterior tibial artery perforator flaps based on predictable perforators provide reliable coverage of patella and knee defects, bestowing versatility and flexibility to the reconstructive surgeons armamentarium.

Outcome of Neurolysis for Failed Tarsal Tunnel Surgery

Revision tarsal tunnel surgery was performed on 44 patients (two bilaterally). The surgical procedure included a neurolysis of the tibial nerve in the tarsal tunnel, the medial plantar, lateral plantar, and calcaneal nerves in their respective tunnels, excision of the intertunnel septum, and neuroma resection as indicated. A painful tarsal tunnel scar or painful heel was treated, respectively, by resection of the distal saphenous nerve or a calcaneal nerve branch. Postoperative, immediate ambulation was permitted. Outcomes were assessed with a numerical grading scale that included neurosensory measurements. Outcomes were also assessed by patient satisfaction and their own estimate of residual pain and/or numbness. Mean follow-up time was 2.2 years. Outcomes in terms of patient satisfaction were 54% excellent, 24% good, 13% fair, and 9% poor results. The mean preoperative numerical score was 6.0 and the mean postoperative score was 2.7. There was a significant improvement seen, based on the median difference between scores (P<0.001). Prognostic indicators of poor results in our patient group were coexisting lumbosacral disc disease and/or neuropathy. An approach related to resecting painful cutaneous nerves and neurolysis of all tibial nerve branches at the ankle offers hope for relief of pain and recovery of sensation for the majority of patients with failed previous tarsal tunnel surgery.