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Summary:. Post traumatic lymphedema (PTL) is a known complication of extremity trauma that is detrimental to limb form and function, healing, and quality of life. In cases of complex lower extremity trauma with vascular and extensive soft tissue injury, the risk of PTL is increased. However, many trauma patients are lost to follow-up, making the risk and potential management of these patients’ lymphedema difficult to characterize. The purpose of this report is to describe the successful surgical management of PTL secondary to significant lower extremity trauma requiring complex limb salvage reconstruction. A 43-year-old woman involved in a motorcycle accident presented with a Gustilo IIIB right tibial fracture and single-vessel leg. She underwent successful limb salvage with serial debridement, bony fixation, creation of an arteriovenous loop with a contralateral saphenous vein graft, and a chimeric latissimus dorsi-serratus anterior muscle flap. At the 5-month follow-up, she presented with significant right lower extremity lymphedema. She underwent lymphovenous bypass surgery guided by preoperative indocyanine green lymphography, which resulted in a 62% improvement in functional outcome measures, eliminated her prior need for compression garments and inability to wear regular shoes, and sustained improvement at two years follow-up. This case illustrates a near circumferential traumatic defect reconstructed with a muscle flap and successful delayed lymphatic reconstruction with lymphovenous bypass in the same patient.

Summary:. Neuroma management has gained significant attention in the peripheral nerve literature in the past decade. Alongside techniques such as targeted muscle reinnervation and regenerative peripheral nerve interface, another technique known as the “allograft to nowhere” has emerged. This approach involves the placement of an extended allograft at the end of a nerve, creating a regrowth zone in cases where muscle or nerve targets are not available. Although technique and outcomes research has been performed regarding the above techniques, there is a lack of imaging studies to examine postoperative outcomes. The authors present a case of recurrent neuroma management using a combined nerve allograft to nowhere + muscle target, supported by postoperative imaging.

Summary:. Thumb tip amputations can be reconstructive challenges, particularly in pediatric patients. Reconstruction using composite grafting and local flap options has been described for tip amputations in the adult population. The authors describe the use of a spare part reconstruction using autologous bone graft and a reverse cross finger flap to preserve length and function for a distal thumb tip amputation in a young man.

Summary:. The serratus anterior-rib composite flap is a well described and versatile flap used for reconstruction in a variety of anatomical regions. However, reconstruction of a thumb defect using this flap has not been well described since first mentioned in the literature by the Buncke et al group 20 years ago. The authors describe the use of this technique for thumb reconstruction in a complex defect from a gunshot wound.

Summary:. Male genital lymphedema is a debilitating condition with significant physiologic and psychologic ramifications. Classical surgical treatments for male genital lymphedema include primarily ablative procedures through removal of excess soft tissue, which often have poor aesthetic and functional outcomes. Super microsurgical techniques (including lymphovenous bypass and lymph node transfers) are promising contemporary interventions. In this case report, we aim to share our experience of lymphovenous bypass with indocyanine green (ICG) lymphangiography in the management of penile and scrotal lymphedema. We performed ICG lymphography of the male genitalia and right thigh by injecting ICG at multiple sites followed by concomitant evaluation with a handheld fluorescent portable imager. Skin incisions were designed over the linear lymphatics upstream from the site of obstruction and dermal backflow. Four end-to-end and one end-to-side lymphovenous bypasses were performed. After completion, lymphovenous bypasses patency was confirmed by injecting ICG proximal to the incision and observing flow. At 10-month clinic follow-up, the patient showed marked improvement with improved skin tenting, softer tissues, improved sensation, visible dorsal penile vein, ability to retract foreskin for cleaning, and confidence to engage in sexual activities. This case report describes successful use of lymphovenous bypass in the treatment of penile and scrotal lymphedema using ICG lymphography intraoperatively to map functioning of superficial lymphatics. The full potential of this microsurgical approach is yet to be discovered, and future studies are needed to enhance the long-term outcomes for the treatment of penoscrotal lymphedema.

Summary:. Infection of the temporomandibular joint (TMJ) is a rare pediatric condition resulting from the introduction of pathogens into the joint by hematogenous seeding, local extension, or trauma. Early recognition of the typical signs and symptoms including fever, trismus, preauricular swelling, and TMJ region tenderness are critical in order to initiate further evaluation and prevent feared complications of fibrosis, ankylosis, abnormal facial structure, or persistence of symptoms. Contrast-enhanced computed tomography with ancillary laboratory analysis including erythrocyte sedimentation rate, C-reactive protein, and white blood cell count are beneficial in confirming the suspected diagnosis and monitoring response to therapy. Initial intervention should include empiric parenteral antibiotics, early mandibular mobilization, and joint decompression to provide synovial fluid for analysis including cultures. This report describes a case of TMJ bacterial arthritis in a healthy 6-year-old male who was promptly treated nonsurgically with intravenous antibiotics and localized needle joint decompression with return to normal function after completion of oral antibiotics and physical therapy.