Hirche, Christoph

BACKGROUND The articular origin of intraneural ganglion cysts has been previously described and well supported, except for the median nerve at the level of the elbow. OBSERVATIONS The authors present a patient with a median intraneural ganglion cyst at the elbow region and magnetic resonance imaging (MRI) evidence of a joint connection to the proximal radioulnar joint. A 63-year-old man presented with thumb flexion weakness and dysesthesias in the thumb, index, and middle fingers. Electromyography confirmed a median nerve lesion at the elbow. MRI demonstrated a median intraneural cyst as well as an extraneural cyst, both arising from the proximal radioulnar joint. The articular branch between the cyst and the proximal radioulnar joint was identified preoperatively on MRI and intraoperatively using indocyanine green. Following disconnection of the articular branch and pedicle and decompression of the intra- and extraneural cysts, the patient recovered grade M4 motor function after 6 months, with resolution of neuropathic pain immediately after surgery. LESSONS The authors present the first case of a median intraneural cyst with a joint connection to the proximal radioulnar joint. The authors believe that this report along with other historical data strengthens the articular theory for intraneural ganglion cysts not only at this site but at all sites. https://thejns.org/doi/10.3171/CASE24564

BackgroundMicrosurgical free flaps for reconstruction of soft tissue defects in lower extremity have evolved into a reliable procedure over last decades; however, there lacked high level of evidence.MethodsA systematic literature research was performed including studies between 2000 and 2014 in English, German, and Chinese (PubMed, EMBASE). Publications were selected applying inclusion/exclusion criteria. Postoperative complications were statistically analyzed with metaprop command of R GUI 3.0.1.ResultsAlltogether 30 articles overlooking 1,397 free flaps were included. The rate of total flap loss was 6.0% (95% confidence interval [CI] = 4.0%–8.0%, PQ (P values of Q statistics) = 0.03); the thrombosis rate was 6.0% (95% CI = 4.0%–9.0%, PQ = 0.01); the hematoma rate was 4.0% (95% CI = 3.0%–5.0%, PQ = 0.79); the partial necrosis rate was 6.0% (95% CI = 4.0%–10.0%, PQ < 0.01); the early infection rate was 4.0% (95% CI = 2.0%–6.0%, PQ = 0.03), and the dehiscence rate was 3.0% (95% CI = 2.0%–5.0%, PQ = 0.12). Reconstruction for diabetic foot may be not associated with a significant increase of procedural risk (Total flap loss rate = 6%, 95% CI = 3.0%–9.0%, PQ = 0.44).ConclusionsMicrosurgical reconstruction of soft tissue defects in the lower extremity reconstruction could be regarded safe and reliable. A standardization of report of perioperative parameters and clinical outcomes is needed. © 2016 Wiley Periodicals, Inc. Microsurgery 36:511–524, 2016.