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Abstract BACKGROUND Patients with severe cubital tunnel syndrome often have poor functional recovery with conventional surgical treatment. Postsurgical electrical stimulation (PES) has been shown to enhance axonal regeneration in animal and human studies. OBJECTIVE To determine if PES following surgery for severe cubital tunnel syndrome would result in better outcomes compared to surgery alone. METHODS Patients with severe cubital tunnel syndrome in this randomized, double-blind, placebo-controlled trial were randomized in a 1:2 ratio to the control or stimulation groups. Control patients received cubital tunnel surgery and sham stimulation, whereas patients in the stimulation group received 1-h of 20 Hz PES following surgery. Patients were assessed by a blinded evaluator annually for 3 yr. The primary outcome was motor unit number estimation (MUNE) and secondary outcomes were grip and key pinch strength and McGowan grade and compound muscle action potential. RESULTS A total of 31 patients were enrolled: 11 received surgery alone and 20 received surgery and PES. Three years following surgery, MUNE was significantly higher in the PES group (176 ± 23, mean + SE) compared to controls (88 ± 11, P < .05). The mean gain in key pinch strength in the PES group was almost 3 times greater than in the controls (P < .05). Similarly, other functional and physiological outcomes showed significantly greater improvements in the PES group. CONCLUSION PES enhanced muscle reinnervation and functional recovery following surgery for severe cubital tunnel syndrome. It may be a clinically useful adjunct to surgery for severe ulnar neuropathy, in which functional recovery with conventional treatment is often suboptimal. Graphical Abstract Graphical Abstract

Background Social relationships, which are contingent on access to social networks, promote engagement in social activities and provide access to social support. These social factors have been shown to positively impact health outcomes. In the current systematic review, we offer a comprehensive overview of the impact of social activities, social networks and social support on the cognitive functioning of healthy older adults (50+) and examine the differential effects of aspects of social relationships on various cognitive domains. Methods We followed PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines, and collated data from randomised controlled trials (RCTs), genetic and observational studies. Independent variables of interest included subjective measures of social activities, social networks, and social support, and composite measures of social relationships (CMSR). The primary outcome of interest was cognitive function divided into domains of episodic memory, semantic memory, overall memory ability, working memory, verbal fluency, reasoning, attention, processing speed, visuospatial abilities, overall executive functioning and global cognition. Results Thirty-nine studies were included in the review; three RCTs, 34 observational studies, and two genetic studies. Evidence suggests a relationship between (1) social activity and global cognition and overall executive functioning, working memory, visuospatial abilities and processing speed but not episodic memory, verbal fluency, reasoning or attention; (2) social networks and global cognition but not episodic memory, attention or processing speed; (3) social support and global cognition and episodic memory but not attention or processing speed; and (4) CMSR and episodic memory and verbal fluency but not global cognition. Conclusions The results support prior conclusions that there is an association between social relationships and cognitive function but the exact nature of this association remains unclear. Implications of the findings are discussed and suggestions for future research provided. Systematic review registration PROSPERO 2012: CRD42012003248 .

Background Painful conditions such as residual limb pain (RLP) and phantom limb pain (PLP) can manifest after amputation. The mechanisms underlying such postamputation pains are diverse and should be addressed accordingly. Different surgical treatment methods have shown potential for alleviating RLP due to neuroma formation — commonly known as neuroma pain — and to a lesser degree PLP. Two reconstructive surgical interventions, namely targeted muscle reinnervation (TMR) and regenerative peripheral nerve interface (RPNI), are gaining popularity in postamputation pain treatment with promising results. However, these two methods have not been directly compared in a randomised controlled trial (RCT). Here, we present a study protocol for an international, double-blind, RCT to assess the effectiveness of TMR, RPNI, and a non-reconstructive procedure called neuroma transposition (active control) in alleviating RLP, neuroma pain, and PLP. Methods One hundred ten upper and lower limb amputees suffering from RLP will be recruited and assigned randomly to one of the surgical interventions (TMR, RPNI, or neuroma transposition) in an equal allocation ratio. Complete evaluations will be performed during a baseline period prior to the surgical intervention, and follow-ups will be conducted in short term (1, 3, 6, and 12 months post-surgery) and in long term (2 and 4 years post-surgery). After the 12-month follow-up, the study will be unblinded for the evaluator and the participants. If the participant is unsatisfied with the outcome of the treatment at that time, further treatment including one of the other procedures will be discussed in consultation with the clinical investigator at that site. Discussion A double-blind RCT is necessary for the establishment of evidence-based procedures, hence the motivation for this work. In addition, studies on pain are challenging due to the subjectivity of the experience and the lack of objective evaluation methods. Here, we mitigate this problem by including different pain evaluation methods known to have clinical relevance. We plan to analyse the primary variable, mean change in NRS (0–10) between baseline and the 12-month follow-up, using the intention-to-treat (ITT) approach to minimise bias and keep the advantage of randomisation. The secondary outcomes will be analysed on both ITT and per-protocol (PP). An adherence protocol (PP population) analysis will be used for estimating a more realistic effect of treatment. Trial registration ClinicalTrials.gov NCT05009394.

Background: Traumatic scalp degloving injuries are associated with substantial morbidity and profound psychosocial impacts. Injury management is complicated by extensive surface area of exposed calvarium and limited availability of local vascularized tissue for coverage. Reconstructive options include advancement of local periosteal, muscle or fascial flaps, regional pedicled flaps or free tissue transfer flaps. Vascularized omental free flaps have been described with good results, but rarely outside the plastic surgery literature. Methods: We present a case of severe traumatic scalp degloving and describe the multidisciplinary operative management approach. Following wound bed preparation, autologous omentum was harvested laparoscopically and used as a vascularized free flap to support a splitthickness skin graft and successfully cover a near-total scalp avulsion injury. Results: A 29-year-old female presented to our level 1 trauma centre following blunt head trauma from agricultural equipment. During advanced trauma life support assessment, secondary survey revealed near total scalp degloving encompassing the forehead and circumferential scalp to the superior nuchal line. The avulsed scalp was fragmented, precluding reimplantation. The patient underwent multiple operative debridements. Wound management consisted of salinesoaked dressings, then negative pressure wound therapy once the wound base was clean. Despite elevation of local periosteal and temporalis muscle advancement flaps, incomplete calvarial coverage rendered primary skin graft reconstruction impossible. Plastic and general surgery teams collaborated to plan for autologous omentum as a vascularized free tissue transfer flap. In a combined procedure, the plastic surgeons prepared the skull and left superficial temporal vessels for free flap transfer, while the general surgeons performed laparoscopic omentectomy with preservation of right gastroepiploic artery and vein. The omentum was removed via laparoscopic retrieval bag and primed with heparinized saline, and a microvascular anastomosis of gastroepiploic to superficial temporal vessels was completed. Indocyanine green confirmed perfusion, and nonilluminating segments were resected. The omental flap was inset along the defect. A split-thickness skin graft was harvested from the patient's thigh, meshed and secured over the omental flap. Neurosurgery applied a halo device to offload the posterior flap/graft for optimal healing. Graft take was excellent with complete coverage and an aesthetic scalp contour. Conclusion: We report a case using laparoscopic retrieval of autologous omentum for successful microvascular free tissue transfer flap reconstruction in a severe traumatic scalp degloving injury. Collaboration between plastic, general and neurosurgery colleagues facilitated this reconstructive technique and yielded excellent functional and cosmetic results for the patient. Omental free flap is an uncommon but useful approach and should be considered part of the management algorithm for traumatic scalp degloving injuries.

Correspondence to Dr Alyssa Catherine MacLean; acmaclea@ualberta.ca Case description A 29-year-old woman presented to our level 1 trauma center following blunt head trauma from agricultural equipment. Positive patient factors—slim body habitus, no prior abdominal operations or procedures, and hemodynamic stability—facilitated a minimally invasive approach to autologous omental harvest. In a combined operative procedure, the plastic surgery team prepared the skull and the left superficial temporal vessels for free flap transfer, while the acute care surgeons performed laparoscopic omentectomy with careful identification and preservation of the right gastroepiploic artery and vein (figure 2A).