[The square pronator: an "aspirin" strip in antalgic surgery for painful neuromas of the wrist]

Muscular branches from the ulnar artery are the basis for a pedicled partial flexor digitorum superficialis muscle flap

The feasibility of a pedicled flexor digitorum superficialis muscle flap was studied in 10 fresh cadavers. The number, length and distance from the flexion wrist crease of muscular branches from the ulnar artery in the distal 10 cm of the forearm were recorded. The mean number of muscular branches was 2.7 (range 1-4). The mean distance of the most distal branch was 35 mm (range 26-40) from the proximal wrist flexion crease. Its mean length was 20 mm (range 16-26). A partial muscle flap was raised on the most distal branch and transposed over the median nerve in the distal forearm. Dissection and transposition of this flap were feasible in all specimens. The reliable pattern of muscular branches to the flexor digitorum superficialis allows the elevation of a pedicled partial muscle flap that can cover the median nerve in the distal forearm.Level of evidence: V.

[The modified Lamberty and Cormack's flap for neuropathies of the ulnar nerve at the elbow]

Surgical treatment of ulnar nerve syndrome at the elbow gives good results in the majority of cases but there are sometimes incomplete results or recurrences that can lead to iterative procedures. This iterative surgery is responsible for painful neurological sequelae often resistant to pharmacological treatments. In these selected resistant cases, we made the choice of a surgical treatment associating a neurolysis of the ulnar nerve and wrapping with a vascularized flap modified from Lamberty and Cormack. This retrospective study focused on six cases with an average follow-up of 30 months. The results showed an improvement in all patients, especially for the two criteria which best reflect the neuropathic pain: DN4 questionnaire and the visual analog scale of pain. Even if it is a short study, it commits us to continue to apply the principle of covering ulnar neuropathy at the elbow by a vascularized flap.

Perineural fat grafting in the treatment of painful end-neuromas of the upper limb: a pilot study

The purpose of this study was to evaluate the effectiveness and middle-term durability of the results achieved with perineural fat grafting of painful neuromas of the upper limb. We retrospectively analysed eight patients, affected by eight neuromas, treated by neuroma excision and fat grafting around the proximal nerve stump. Clinical parameters, the disabilities of the arm shoulder and hand score, and the visual analogue scale were recorded at 2, 6 and 12 months after surgery. A reduction of 23.2% was observed in the mean disabilities of the arm shoulder and hand scores at 12 months. The spontaneous baseline visual analogue scale score showed a mean improvement of 22% at 12 months, although not this was not statistically significant. Perineural fat grafting is a quick and useful procedure and could represent a useful primary operation in the treatment of pain syndromes of neuropatic origin.

Perineural fat grafting in the treatment of painful neuromas

Treatment of painful neuromas of the upper limb has been largely debated. The current surgical treatments spare from simple neuroma excision to proximal nerve stump relocation (into muscles, veins, and bones). Perineural fat grafting consists of neuroma excision and the creation of an autologous adipose graft wrapped around the proximal nerve stump. This technique should be prescribed to those patients suffering from terminal neuromas or neuromas in which functional reconstruction is contraindicated. The effectiveness of this technique could be addressed both to the mechanical and biological properties of the fat graft. On one hand the graft creates a gliding layer and a protective barrier, thus allowing longitudinal excursion and protection against mechanical solicitations. On the other hand the autologous adipose tissue brings neoangiogenesis, modulates the inflammatory response, and avoids scar adherences. A retrospective analysis was performed on 7 neuromas in 7 patients, treated with perineural fat grafting from June 2009 to February 2010. Pain and limb functionality were measured, respectively, with a visual acuity scale and the "Disabilities of the Arm, Shoulder, and Hand score," preoperatively and 1 year after surgery. A mean pain reduction of 23% was recorded, without relevant complications. Improvements in limb functionality were also observed through the measurement of the Disabilities of the Arm, Shoulder, and Hand score, which improved to 18%. We believe that this technique represents a valuable and versatile option in the treatment of painful neuromas of the upper limb that could be hereafter performed for pain syndromes of neuropatic origin.

Pedicle and free flaps for painful nerve

Treatment of the chronic painful nerve by pedicled or free tissue transfer is a complex surgical procedure, requiring specialized microsurgical training and technique. This procedure is indicated only in patients who have had repeated failure of simpler, conventional procedures. Patients with chronic painful peripheral nerves may be potentially salvaged by external neurolysis and circumferential wrapping of the involved segments of nerve with well-vascularized pedicled or free flaps of fascia, subcutaneous fatty tissue, omentum or muscle, or by the replacement of superficial hypersensitive cutaneous areas and nerves with the same tissues.

Coverage of painful peripheral nerve neuromas with vascularized soft tissue: method and results

OBJECTIVE

Our goals are to describe a method of treating painful peripheral nerve neuromas by means of vascularized tissue coverage, report the results in seven patients, and discuss the indications for this treatment modality. An analysis of pain, functionality of the affected body part, professional activities of the patients, and medications before and after surgery is presented.

METHODS

Seven male patients (mean age, 45.1 yr) with posttraumatic nerve injuries, who had developed painful stump neuromas or neuromas-in-continuity, and who had unsuccessfully undergone several treatment procedures, were selected for the surgery described here. The operation included resection of the stump neuroma (four patients) or neurolysis of the neuroma-in-continuity (three patients) and coverage of the nerve with a vascularized fascial, fasciocutaneous, or perforator flap (three pedicled regional flaps and four free flaps). A modified quadruple visual analog scale was used to quantify pain before and after surgical treatment. The mean follow-up was 16.6 months.

RESULTS

The mean values of the quadruple visual analog scale (pain now/typically/at its best/at its worst) before surgery were 6.5/6.5/4.7/7.9. These values changed to 0.3/0.4/0/0.9 at a mean follow-up of 16.6 months after surgery. Five patients returned to their original profession, one receives a pension, and one began a less demanding job after undergoing surgery. Six of the seven patients received opioids before surgery (one had a spinal cord stimulator). After surgery, all patients stopped taking regular pain killers and the spinal cord stimulator was deactivated in one; two patients still take nonsteroidal anti-inflammatory drugs occasionally, but not on a regular basis.

CONCLUSION

Vascularized soft tissue coverage of painful peripheral nerve neuromas seems to be an effective and attractive, but also complex, method of treatment. This option may be considered and reserved for patients who have already undergone several pain treatment modalities without success.