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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:. Finger entrapment with rings or ring-like objects is an uncommon possible hand emergency. In cases in which noncutting removal is ineffective, ring cutters or dental drills with carbide or diamond burs have been successfully used. However, objects composed of hard metallic alloys, such as lug nuts or wrenches, are often resistant to such equipment. In these instances, larger diameter metal cutting burrs or rasps may be more advantageous. Due to their increased size and cutting power, these tools are better suited to handle the toughness of hard metals. In this case report, we present the effective and efficient removal of a stainless steel wrench from an entrapped digit using a helicoidal rasp. Availability of this instrument within orthopedic departments may prevent the delays often described in the treatment of finger entrapment when traditional cutting equipment fails.

Summary:. Vascularized lymph node transfer (VLNT) is a reliable treatment for patients with chronic lymphedema. Capillary networks in VLNT are less robust than those in traditional free tissue transfers, possibly contributing to venous congestion when a single arterial and venous anastomosis is performed. This technical report describes a novel operative technique and associated advantages to a functional flow-through VLNT with two end-to-side arterial anastomoses. Six consecutive patients with upper or lower extremity lymphedema received buried supraclavicular or submental VLNT with two end-to-side arterial anastomoses and at least one venous anastomosis. Recipient arteries in the anastomoses were the brachial artery for patients with upper extremity lymphedema (n = 4), and the posterior tibial vasculature in patients with lower extremity lymphedema (n = 2). Five patients simultaneously underwent lymphovenous bypass. Mean patient follow-up was 14 months. Average preoperative Lymphedema Life Impact Score and L-DEX (bioimpedance spectroscopy measurement) were 25 points and 31.4 units, with a mean greatest decrease of 20 points and 9.4 units postoperatively (n = 5). The loop configuration created by flow-through VLNT with two end-to-side arterial anastomoses may reduce pressure gradients within the flap by limiting arterial inflow and thus, mitigate the risk of venous hypertension. Additional benefits of this approach include elimination of mismatch caliber discrepancies often appreciated in end-to-end arterial anastomosis between the lymph node flap and the recipient artery, and preservation of the recipient artery anatomy.

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.

Lymphedema is a chronic debilitating disease in which impaired drainage of lymphatic fluid causes accumulation of fluid in the soft tissues resulting in a swollen heavy limb. This ultimately leads to severe fibrosis, recurrent infections, non-healing wounds, and a poorly functioning limb that negatively affects a patient's quality of life. Primary lymphedema is due to abnormal development of the lymphatic system and patients can present with lymphedema at birth or later in life. Secondary lymphedema is caused by damage to the lymphatic system from infection, surgery to treat malignancies, trauma, and obesity. In the past, the only treatment was controlling the swelling to prevent progression of the disease by lymphatic therapy and various types of compression which is still currently the first line treatment. Advances in supermicrosurgery (connecting vessels less than 0.8 mm) have made way for surgical treatment options for lymphedema, including lymphovenous bypass and vascularized lymph node transplant. These new surgical treatment options combined with lymphatic therapy and compression have led to better results and improved patient's quality of life. After reading this article, the participant should be familiar with diagnosis, imaging, and surgical treatment of lymphedema., (Copyright 2020 by the Missouri State Medical Association.)