Handchirurgie Mikrochirurgie Plastische Chirurgie最新文献

Background: Lesions of peripheral nerves of the upper extremities often lead to persistent, serious limitations in motor function and sensory perception. Affected patients suffer from both private and professional restrictions associated with long-term physical, psychological and socioeconomic consequences.

Indication: An early indication for a nerve transfer shortens the reinnervation distance and improves the growing of motor and sensory axons into the target organ to facilitate early mobility and sensitivity. When planning the timepoint of the surgical procedure, the distance to be covered by reinnervation as well as the morbidities of donor nerves must be considered individually.

Results: Nerve transfers can achieve earlier and safer reinnervation to improve motor and sensory functions after nerve injuries in the upper extremity.

Uncommon nerve compression syndromes: In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.

We present the Nerve Club, a community of colleagues originating from german-speaking countries and dedicated to those working in or outside surgery with interest in the peripheral nerve. This article reviews the club´s history and specific characteristics and activities, and highlights the concept of a certificate in nerve surgery. We have annual club meetings and organize every two years a plexus symposium. Also exists a scientific publication award and cooperation with an online based journal dedicated to medical publications in the field of nerve surgery.

Background: Neuralgic amyotrophy (NA) is a monofocal or oligofocal inflammatory neuropathy whose incidence has been significantly underestimated. A connection between constrictions and torsions of peripheral nerves with this disease has been increasingly established in recent years. Modern imaging techniques such as high-resolution nerve ultrasound and MR neurography have contributed to a better understanding of the pathophysiology and a better assessment of the prognosis of the disease. This has led to the concept of treating patients with such focal changes surgically in order to improve the prognosis. This review presents current ideas on the pathophysiology, clinical presentation, diagnosis and treatment of the disease.

Patients and methods: In a retrospective study, pre-, intra- and postoperative findings of 22 patients with 23 constrictions/torsions of peripheral nerves of the upper extremity were analysed. The patients underwent surgery at a nerve surgery centre over a period of 3.5 years (Dec. 2019-May 2023). The median nerve was most frequently affected (N=9), followed by the suprascapular nerve (N=6) and radial nerve (N=4). The axillary nerve (N=3) and the accessory nerve (N=1) were also involved. Surgical exploration revealed nerve torsions (N=9), nerve constrictions (N=5), fascicular torsions (N=12) and fascicular constrictions (N=9). Depending on the intraoperative findings, epineuriotomies (N=1), epi- and perineuriotomies (N=33), end-to-end sutures (N=2), and one epi- and one perineural suture were performed.

Results: After an average follow-up of 10 months (3-28 months), 17 patients were re-examined. All of them reported a clear subjective improvement in motor deficits. Clinically and electromyographically, a reinnervation and significant increase in strength from a pre-existing strength grade of M0 to at least M3 in the vast majority of affected muscles was demonstrated in these patients.

Summary: The incidence of NA continues to be underestimated and, in a significant proportion of patients, leads to permanent motor deficits, most likely due to constrictions and torsions of affected nerves. Surgical treatment is recommended as early as possible. Very good results can usually be achieved with epi- and perineuriotomy. In rare cases, end-to-end neurorrhaphy or nerve grafting is required.

Introduction: A supracondylar process is a bony spur on the distal anteromedial surface of the humerus, and it is considered an anatomical variant with a prevalence of 0.4-2.7% according to anatomical studies. In almost all cases, it is associated with a fibrous, sometimes ossified ligament, which extends from the supracondylar process to the medial epicondyle. This ligament is known in the literature as the ligament of Struthers, named after the Scottish anatomist who first described it in detail in 1854. In rare cases, the supracondylar process can be a clinically relevant finding as a cause of nerve compression syndrome. The median and ulnar nerve can be trapped by the ring-shaped structure formed by the ligament of Struthers and the supracondylar process.

Case report: A 59-year-old patient with symptoms of a cubital tunnel syndrome and additional ipsilateral sensory deficits in his thumb was referred to our clinic. Electroneurography showed no signs of an additional carpal tunnel syndrome. Preoperative x-ray and CT scans of the upper arm revealed a supracondylar process, which led us to suspect an associated entrapment of the median nerve. An MRI scan of the upper arm showed a ligament of Struthers and signs of a related median nerve compression as we initially assumed. We performed a surgical decompression of the median nerve in the distal upper arm and of the ulnar nerve in the cubital tunnel. Intraoperatively, there was evidence of compression of the median nerve due to the supracondylar process and the ligament of Struthers. The latter was cleaved and then resected along with the supracondylar process. Three months after surgery, the patient had no motor or sensory deficits.

Summary: The ring-shaped structure formed by the supracondylar process and ligament of Struthers represents a rare cause of compression syndrome of the median and ulnar nerve. Its incidence remains unknown so far. This anatomical variant should be considered a differential diagnosis in case of possibly related nerve entrapment symptoms after ruling out other, more frequent nerve compression causes. Moreover, the supracondylar process should be completely resected including the periosteum during surgery to minimise the risk of recurrence.

Background: The treatment of obstetric brachial plexus palsy through primary reconstruction and nerve transfers has been established in the past decades. In the case of non-traumatic diseases that lead to flaccid paralysis and the inability to move the extremities, such as transverse myelitis (TM) or arthrogryposis multiplex congenita (AMC), which can have a wide variety of causes, the focus has been on rehabilitative therapy so far, while surgical interventions have been used to a lesser extent, e. g., in the form of osteotomies or muscle transfers. Our aim is to establish nerve transfers as a surgical option to improve mobility in non-traumatic amyoplasia.

Patients: This work presents the needs-adapted treatment of a total of 23 patients (aged 4 months to 64 months, 18 with AMC and 5 with TM) using nerve transfers on the upper extremity.

Results: We were able to show that early nerve transfers in the upper extremity enabled the reanimation of muscles in both AMC and TM.

Conclusion: This work shows that the treatment of non-traumatic amyoplasia in children with selective nerve grafts is a successful method. Nerve transfers allow patients to gain or regain important functions for managing independent everyday life. The surgical methods have been established in the treatment of traumatic nerve injuries. They are well-known and can be carried out safely. We believe that this is an important treatment option for paediatric patients with paralysis associated with TM or AMC, which should also be known to the treating physicians.

Introduction: The process of continuous acquisition of surgical expertise is a key element in registrar training. The principle of active, self-directed learning, which is regularly applied in medical school, can also be used to gain surgical expertise in registrar training.

Methods: Surgical training can be compared to acquiring expertise in music or sport, where both intellectual and manual capabilities are required. Specific training principles, including analysis, goal setting, practice and reflection on the process, are commonly encountered in these fields. Smart goal setting is preferred in order to ensure compliance and a successful strategy. This can also be used in plastic surgery training.

Application: Surgical principles as well as partial or complete surgical procedures can be practiced using the smart principle. The fragmentation of a larger task into smaller units allows rapid acquisition of surgical expertise without impeding patient safety.

Discussion: Surgical training today happens in a setting caught between economic and medicolegal challenges. The reduction of case load requires simulation practice as well as self-directed learning - which has been shown to improve outcomes. The smart principle allows distinct goal setting which can improve compliance of the student and increase success. As this form of learning is not intuitive to all individuals, supervisors and mentor can support trainees in the acquisition of surgical expertise using this principle.