Behandlung des Morbus Sudeck

Complex regional pain syndrome (CRPS) was formerly known as “Sudeck’s atrophy”. The disease belongs to the group of neuropathic pain syndromes and is differentiated into three types. Type I is characterized by a lack of nerve lesions, type II by the presence of nerve lesions, and type III by the presence of other entities such as fibromyalgia. The exact pathogenic factors leading to the disease are still unknown and are currently the subject of investigation in various studies. These studies suggest a contribution of the central nervous system to the development and maintenance of CRPS. However, the clinical symptoms are well documented and include pain, autonomic changes and impaired motor function of the affected extremity. Diagnosis is based clinically on signs and symptoms. However, in a few cases radiography and scintiscanning may be useful to finalize the diagnosis. The treatment options are centred on the symptoms of pain, autonomic changes and functional impairment. A multidisciplinary treatment strategy is recommended, with surgeons, anaesthesiologists, physiotherapists and psychotherapists working together. Surgical intervention in this disease is only required in rare cases of neurological and bone pain, and the indications for such intervention are narrow and should be strictly observed.     

Free flap monitoring with continuous tissue oxygen tension measurement

Intraoperative and postoperative free flap monitoring by means of oxygen tension measurement was carried out in 11 patients. We used an invasive flexible microcatheter that allowed for measurement of oxygen tension in all types of free flaps. Two cases of the measured flaps were buried free flaps which do not allow monitoring by clinical assessment. All flaps monitored in this study survived. One case of displacement of the microcatheter occurred. In one patient, the tissue pO₂ monitor successfully detected early vascular thrombosis with subsequent reoperation and salvage of the free flap.     

Restoration of shoulder abduction function by direct muscular neurotization with the phrenic nerve fascicles and nerve grafts: A case report

In this report, we describe the first case of using the partial phrenic nerve transfer and direct muscular implantation into the deltoid muscle for restoration of the shoulder function and stability. A patient suffering from the partial brachial plexus injury with absent axillary nerve underwent reconstructive surgery by an end‐to‐end nerve coaptation using two fascicles of the phrenic nerve and two autologous nerve grafts, and direct implantation of nerve grafts into the deltoid muscle. Eighteen months after the procedure, we found a functioning biceps with 90° elbow flexion against gravity and 40° shoulder abduction with satisfactory shoulder stability. Electrophysiology revealed reinnervation potentials in the deltoid and biceps muscle. This case demonstrates a satisfactory result after using transfer of the partial ipsilateral phrenic nerve in combination with muscular implantation to restore shoulder abduction and stability. We recommend the described techniques in cases without other reconstructive options. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Brachial plexus lesions: 10 years of experience in a center for microsurgery in Germany

Aim: Brachial plexus lesions are commonly associated with complete or partial plegia of affected muscles even after microsurgical treatment. This study provides an overview of strategies and outcomes of 42 patients operated in a center for peripheral nerve surgery in Germany. Methods: Postsurgically, the patients were followed up and examined for strength in various muscle groups by applying a standard clinical classification (M0–M5). Sensitivity was estimated by differentiation between blunt and sharp touch. The patients were asked via questionnaire about their postsurgical daily life. Most of the patients received a grafting procedure using the sural nerve. Different microsurgical techniques were applied according to the underlying pathology: Intercostal nerve transfer, end‐to‐side coaptation, and direct grafting to different recipient nerves. Results: Only the 27 patients, who had a follow‐up time of at least 36 months, presented a measurable function in the affected extremity. Elbow‐flexion was restored in 15 cases. Triceps function was reconstructed in 7 patients of 27. One patient was able to move digits toward the palm without completing a full fist. Ten patients were able to flex the wrist and 4 could extend it. Conclusion: The results were estimated as acceptable for biceps reconstruction but poor for the other muscle groups. Some treatment strategies, which are presently under frequent discussion (contralateral C7‐transfer, banked autografts, Oberlin procedure), were not applied. However, some of these techniques may provide a key to improve the results. © 2008 Wiley‐Liss, Inc. Microsurgery, 2009.     

Manual stimulation of the orbicularis oculi muscle improves eyelid closure after facial nerve injury in adult rats

We have shown that manual stimulation of rat whisker-pad muscles following facial-facial-anastomosis (FFA) restores normal whisking by lowering the proportion of polyinnervated motor endplates. Here we examined whether manual stimulation of the orbicularis oculi muscle (OOM) after FFA would also improve outcome. Blink responses to standardized air puffs were analyzed using video-based motion analysis. Two months after FFA, blink capacity was impaired, as indicated by a largely increased minimum distance between the eyelids after air-puff stimulation compared with intact rats (2.7 +/- 0.4 vs. 0.2 +/- 0.01 mm). Manual stimulation reduced this deficit by a factor of two (1.3 +/- 0.5 mm). The functional improvement after manual stimulation was associated with a 2-fold decrease in the proportion of polyinnervated OOM endplates (21 +/- 10% vs. 42 +/- 10% without manual stimulation, 0% in intact rats). We conclude that manual stimulation is a noninvasive and simple procedure with immediate potential for clinical rehabilitation of eyelid closure following facial nerve injury.     

Free latissimus dorsi flap with long venous grafts for closure of a soft tissue defect of the spine in a patient with Noonan's syndrome: A case report

A 23‐year‐old male patient was operated for a soft tissue defect of the spine using a free musculocutaneous latissimus dorsi flap with two 21‐cm long venous grafts connecting the flap to its vascular supply at the thoracodorsal vessels. This young patient suffered from Noonan's Syndrome that is a complex hereditary malformation syndrome with clinical features often leading to spinal deformities and gibbus development. The defect originated from a former internal vertebral fixation that was necessary for erective correction of such a spinal deformity. After perforation of the introduced material and debridement the defect was 4 × 8 cm in size, which was successfully closed by the free latissimus dorsi transfer. However, two venous grafts were necessary because the extension of the pedicled muscle was not sufficient to reach the defect. This is the first case in literature where a free flap was used with two venous grafts to close a soft tissue defect of the spine in the special case of a vertebral deformity based on a Noonan's Syndrome. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

Manual stimulation of forearm muscles does not improve recovery of motor function after injury to a mixed peripheral nerve

Transection and re-anastomosis of the purely motor facial nerve leads to poor functional recovery. However, we have recently shown in rat that manual stimulation (MS) of denervated vibrissal muscles reduces the number of polyinnervated motor endplates and promotes full recovery of whisking. Here, we examined whether MS of denervated rat forearm muscles would also improve recovery following transection and suture of the mixed (sensory and motor) median nerve (median–median anastomosis, MMA). Following MMA of the right median nerve, animals received no postoperative treatment, daily MS of the forearm muscles or handling only. An almost identical level of functional recovery, measured by the force of grip in grams, was reached in all animals by the sixth postoperative week and maintained till 3 months following surgery regardless of the postoperative treatment. Also, we found no differences among the groups in the degree of axonal sprouting, the extent of motor endplate polyinnervation and in the soma size of regenerated motoneurons. Taken together, we show that while MS is beneficial following motor nerve injury, combined strategies will be required for functional recovery following mixed nerve injury. S. A. Dunlop and D. N. Angelov contributed equally and share last authorship.     

Sonography of brachial plexus traction injuries

OBJECTIVE: Our purpose was to evaluate the feasibility of sonography in identifying nerve abnormalities in patients with traction injury of the brachial plexus. CONCLUSION: Sonography of the brachial plexus was technically feasible, although the entire brachial plexus could not be evaluated. Sonography appears to be a useful bedside imaging technique for assessing brachial plexus injury. The potential of sonography as a complementary diagnostic tool in the evaluation of these patients warrants further investigation.