Michael C. Nicoson

Two-level motor nerve transfer for the treatment of long thoracic nerve palsy

The authors report a case of long thoracic nerve (LTN) palsy treated with two-level motor nerve transfers of a pectoral fascicle of the middle trunk, and a branch of the thoracodorsal nerve. This procedure resulted in near-total improvement of the winged scapula deformity, and a return of excellent shoulder function. A detailed account of the postoperative physical therapy regimen is included, as this critical component of the favorable result cannot be overlooked. This case establishes the two-level motor nerve transfer as a new option for treating LTN palsy, and demonstrates that nerve transfers should be considered in the therapeutic algorithm of an idiopathic mononeuritis.

211B: PROCESSED ALLOGRAFT VERSUS COLD-PRESERVATION ON NERVE REGENERATION: A COMPARISON STUDY

Methods: Thirty-six Lewis rats were randomized into four treatment groups (n=8 per group), depending on the type of graft or conduit utilized, for repair of a 14 mm nerve gap in a sciatic nerve injury model. The four groups, listed A-D were: (A) Cold preserved (CP) nerves, (B) Axogen processed nerve allografts (Axo), (C) Isografts (Iso) serving as the positive control, and (D) Empty silicone conduits (Cond) serving as the negative control. All animals were followed for 6 week post-injury repair. At this time point, nerves from all experimental groups were harvested for standard histomorphometric analysis.

Lower Extremity Reconstruction with Free Gracilis Flaps.

Background There have been significant advancements in lower extremity reconstruction over the last several decades, and the plastic surgeons armamentarium has grown to include free muscle and fasciocutaneous flaps along with local perforator and propeller flaps. While we have found a use for a variety of techniques for lower extremity reconstruction, the free gracilis has been our workhorse flap due to the ease of harvest, reliability, and low donor site morbidity. Methods This is a retrospective review of a single surgeons series of free gracilis flaps utilized for lower extremity reconstruction. Demographic information, comorbidities, outcomes, and secondary procedures were analyzed. Results We identified 24 free gracilis flaps. The duration from injury to free flap coverage was ≤ 7 days in 6 patients, 8–30 days in 11 patients, 31–90 days in 4 patients, and > 90 days in 3 patients. There were 22 (92%) successful flaps and an overall limb salvage rate of 92%. There was one partial flap loss. Two flaps underwent incision and drainage in the operating room for infection. Two patients developed donor site hematomas. Four patients underwent secondary procedures for contouring. Our subset of pediatric patients had 100% flap survival and no secondary procedures at a mean 30‐month follow‐up. Conclusion This study demonstrates the utility of the free gracilis flap in reconstruction of small‐ to medium‐sized defects of the lower extremity. This flap has a high success rate and a low donor site morbidity. Atrophy of the denervated muscle over time allows for good shoe fit, often obviating the need for secondary contouring procedures.

Donor nerve sources in free functional gracilis muscle transfer for elbow flexion in adult brachial plexus injury

With complete plexus injuries or late presentation, free functional muscle transfer (FFMT) becomes the primary option of functional restoration. Our purpose is to review cases over a 10‐year period of free functioning gracilis muscle transfer after brachial plexus injury to evaluate the effect of different donor nerves used to reinnervate the FFMT on functional outcome.

Rectus Abdominis Motor Nerves as Donor Option for Free Functional Muscle Transfer: A Cadaver Study and Case Series.

Background: Current management of brachial plexus injuries includes nerve grafts and nerve transfers. However, in cases of late presentation or pan plexus injuries, free functional muscle transfers are an option to restore function. The purpose of our study was to describe and evaluate the rectus abdominis motor nerves histomorphologically and functionally as a donor nerve option for free functional muscle transfer for the reconstruction of brachial plexus injuries. Methods: High intercostal, rectus abdominis, thoracodorsal, and medial pectoral nerves were harvested for histomorphometric analysis from 4 cadavers from levels T3-8. A retrospective chart review was performed of all free functional muscle transfers from 2001 to 2014 by a single surgeon. Results: Rectus abdominis nerve branches provide a significant quantity of motor axons compared with high intercostal nerves and are comparable to the anterior branch of the thoracodorsal nerve and medial pectoral nerve branches. Clinically, the average recovery of elbow flexion was comparable to conventional donors for 2-stage muscle transfer. Conclusion: Rectus abdominis motor nerves have similar nerve counts to thoracodorsal, medial pectoral nerves, and significantly more than high intercostal nerves alone. The use of rectus abdominis motor nerve branches allows restoration of elbow flexion comparable to other standard donors. In cases where multiple high intercostal nerves are not available as donors (rib fractures, phrenic nerve injury), rectus abdominis nerves provide a potential option for motor reconstruction without adversely affecting respiration.

Utilizing Reverese End-to-Side Neurorrhaphies in Peripheral Nerve Injuries

METHODS: 36 Lewis rats were divided into 3 groups (Figure 1). In Group 1, the right tibial nerve is transected and axonal regeneration from the proximal stump is prohibited. In Group 2, the tibial nerve is transected as described previously. The peroneal nerve is transected distally and coapted to the distal tibial nerve in an end-to-end (ETE) fashion. In Group 3, the tibial nerve is transected as described previously. The peroneal nerve is transected distally and coapted to a perineurial window in the side of the distal tibial nerve in a reverse end-to-side fashion (RETS). In addition, 5 male transgenic Sprague Dawley rats, expressing GFP in neural tissue, underwent the procedure described for Group 3. In these animals, axonal regeneration is visualized over time using confocal microscopy for qualitative assessment. Evaluated outcomes were recorded at two time points (5 and 10 weeks) and included muscle mass, nerve histomorphometry, and nerve stimulation. A one way ANOVA was used to identify differences between individual groups. If significant, a Student Newman-Keuls test was performed for a pairwise multiple comparison.