Background The sural nerve is the most common nerve graft donor despite requiring a second operative limb and causing numbness of the lateral foot. The purposes of this study were to review our experience using nerve autografts in upper extremity nerve reconstruction and develop recommendations for donor selection. Methods A retrospective case series study was performed of all consecutive patients undergoing nerve grafting procedures for upper extremity nerve injuries over an 11-year period (2001-2012). Results Eighty-six patients received 109 nerve grafts over the study period. Mean patient age was 42.9±18.3 years; 57 % were male. There were 51 median (59 %), 26 ulnar (30 %), 14 digital (13 %), 13 radial (16 %), and 3 musculocutaneous (4 %) nerve injuries repaired with 99 nerve autografts (71 from upper extremity, 28 from lower extremity). Multiple upper extremity nerve autograft donors were utilized, including the medial antebrachial cutaneous nerve (MABC), third webspace branch of median, lateral antebrachial cutaneous nerve (LABC), palmar cutaneous, and dorsal cutaneous branch of ulnar nerve. By using an upper-extremity donor, a second operative limb was avoided in 58 patients (67 %), and a second incision was avoided in 26 patients (30 %). The frequency of sural graft use declined from 40 % (n=17/43) to 11 % (n=7/64). Conclusions Our algorithm for selecting nerve graft material has evolved with our growing understanding of nerve internal topography and the drive to minimize additional incisions, maximize ease of harvest, and limit donor morbidity. This has led us away from using the sural nerve when possible and allowed us to avoid a second operative limb in two thirds of the cases.

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Our study showed that the occurrence of HAT is avoidable. Identifying risk factors associated with HAT, meticulous surgical techniques, and careful routine flow monitoring are mandatory to avoid disastrous complications.

Background Management of facial paralysis in older patients is controversial. The purpose of this study is to evaluate the impact of increasing age on functioning free muscle transplantation (FFMT). Patients and Methods Twenty‐nine facial paralysis patients over 50 years old received FFMT. A separate group of patients aged 41–50 years old were included as control. Outcome assessments included use of the SMILE evaluation system for excursion, a cortical adaptation scoring system for brain plasticity, and a subjective satisfaction assessment score. Meta‐analysis of literature over the past 50 years was also performed to examine the impact of older age. Results The mean change in excursion movement was 13.39 ± 5.49 mm. Weakest excursion was found in the oldest age group (11.74 ± 4.84 mm, p = .097), in concordance with the meta‐analysis. There was significant difference between the three different neurotizers (p = .036). Excursion and satisfaction score were significantly worse in the older cohort with the cross face‐nerve graft FFMT. Conclusions FFMT is a viable option in the elderly patient group but performs weaker in excursion. The choice of neurotizer is dependent on the patient's goals and the suitable age at which the benefits outweigh the risks.

Background: Common peroneal neuropathy shares the same pathophysiology as carpal tunnel syndrome. However, management is often delayed because of the traditional misconception of recognizing foot drop as the defining symptom for diagnosis. The authors believe recognizing common peroneal neuropathy before foot drop can relieve pain and help improve quality of life. Methods: One hundred eighty-five patients who underwent surgical common peroneal neuropathy decompression between 2011 and 2017 were included. The mean follow-up time was 249 ± 28 days. Patients were classified into two stages of severity based on clinical presentation: pre–foot drop and overt foot drop. Demographics, presenting symptoms, clinical signs, electrodiagnostic studies and response to surgery were compared between these two groups. Multivariate regression analysis was used to identify variables that predicted outcome following surgery. Results: Overt foot drop patients presented with significantly lower preoperative motor function (percentage of patients with Medical Research Council grade ≤ 1: overt foot drop, 90 percent; pre–foot drop, 0 percent; p < 0.001). Pre–foot drop patients presented with a significantly higher preoperative pain visual analogue scale score (pre–foot drop, 6.2 ± 0.2; overt foot drop, 4.6 ± 0.3; p < 0.001) and normal electrodiagnostic studies (pre–foot drop, 31.4 percent; overt foot drop, 0.1 percent). Postoperatively, both groups of patients showed significant improvement in quality-of-life score (pre–foot drop, 2.6 ± 0.3; overt foot drop, 2.7 ± 0.3). Patients with obesity or a traumatic cause for common peroneal neuropathy were less likely to have improvements in quality of life after surgical decompression. Conclusion: Increased recognition of common peroneal neuropathy can aid early management, relieve pain, and improve quality of life. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

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