Wrist fusion in posttraumatic brachial plexus palsy

Wrist Arthrodesis Using a Trapezoidal Wedge Graft from the Distal Radius and a Low-Profile Reconstruction Plate

Background

Various intramedullary or dorsally based fusions have been utilised to perform wrist arthrodesis. Although the dorsal plate is rigid and well constructed, the standard of care was replenishing the arthrodesis site with an iliac crest bone graft. Due to the high morbidity of the donor site, alternatives such as distal radius bone grafts have gained popularity. In this study, wrist arthrodesis was performed with a locally accessible trapezoidal wedge graft from the distal radius and a low-profile reconstruction plate to evaluate the radiological and functional outcome.

Methods

We retrospectively reviewed 22 wrists, 14 brachial plexus injuries, 4 post-traumatic injuries, and 4 rheumatoid arthritis patients, with a mean follow-up of 31 months. Union was evaluated on radiography. The functional outcomes were evaluated using a visual analog scale incorporated into a questionnaire.

Results

All 22 fusions united successfully, with a mean duration of 12 weeks and a wrist position of an average 17.5 degrees of extension and 6 degrees of ulnar deviation. The aesthetics of the wrist showed the most significant change, and overall satisfaction levels increased.

Conclusions

A locally accessible cortico-cancellous graft from the dorsum of the radius is a reliable alternative to an iliac crest or carpal bone graft with high potential for the union. It also serves as a stable strut in our construct, allowing us to use a low-profile reconstruction plate. The Reconstruction (3.5 System) plate can be used safely with excellent results and a low implant prominence or breakage risk.

Nerve pathology and neuropathic pain after whiplash injury: a systematic review and meta-analysis

ABSTRACT

There is no clear understanding of the mechanisms causing persistent pain in patients with whiplash-associated disorder (WAD). The aim of this systematic review was to assess the evidence for nerve pathology and neuropathic pain in patients with WAD. EMBASE, PubMed, CINAHL (EBSCO), and MEDLINE were searched from inception to September 1, 2020. Study quality and risk of bias were assessed using the Newcastle-Ottawa Quality Assessment Scales. Fifty-four studies reporting on 390,644 patients and 918 controls were included. Clinical questionnaires suggested symptoms of predominant neuropathic characteristic in 34% of patients (range 25%-75%). The mean prevalence of nerve pathology detected with neurological examination was 13% (0%-100%) and 32% (10%-100%) with electrodiagnostic testing. Patients independent of WAD severity (Quebec Task Force grades I-IV) demonstrated significantly impaired sensory detection thresholds of the index finger compared with controls, including mechanical (SMD 0.65 [0.30; 1.00] P < 0.005), current (SMD 0.82 [0.25; 1.39] P = 0.0165), cold (SMD -0.43 [-0.73; -0.13] P = 0.0204), and warm detection (SMD 0.84 [0.25; 1.42] P = 0.0200). Patients with WAD had significantly heightened nerve mechanosensitivity compared with controls on median nerve pressure pain thresholds (SMD -1.10 [-1.50; -0.70], P < 0.0001) and neurodynamic tests (SMD 1.68 [0.92; 2.44], P = 0.0004). Similar sensory dysfunction and nerve mechanosensitivity was seen in WAD grade II, which contradicts its traditional definition of absent nerve involvement. Our findings strongly suggest a subset of patients with WAD demonstrate signs of peripheral nerve pathology and neuropathic pain. Although there was heterogeneity among some studies, typical WAD classifications may need to be reconsidered and include detailed clinical assessments for nerve integrity.

Nerve merging repair in the replantation of a severed limb with defects in multiple nerves: five cases and long-term follow-up

Background

Repairing all nerves is challenging in cases of upper arm avulsion combined with defects in multiple nerves because the donor area for autogenous nerve transplantation is limited and the outcomes of long-segment allogeneic nerve transplantation are poor. Based on the principle of magnified nerve regeneration, we present a method called nerve merging repair, the feasibility of which needs to be confirmed in clinical practice.

Methods

The nerve merging repair method relies on the use of fewer proximal nerves to innervate more distal nerves and depends mainly on whether the radial nerve (RN) can repair itself. In the case of defects in multiple nerves precluding RN self-repair, median-(median + radial) (M-(M + R)) repair is performed. If the RN can undergo self-repair, median-(median + ulnar) (M-(M + U)) or ulnar-(ulnar + median) (U-(U + M)) is used to repair the three nerves. Five cases were included in the study and involved the analysis of joint motor function, muscle strength and sensory recovery of the affected limb.

Results

The replanted limb survived in all 5 cases. Follow-up visits were conducted with the patients for 51–80 months, during which they experienced satisfactory recovery of skin sensation, elbow flexion and extension and partial recovery of hand muscle strength.

Conclusions

To a certain extent, treatment with the nerve merging repair method improved the sensory and motor function of the affected limb and limited the loss of function of the donor nerve area. This intervention provides a new approach for repairing long-segment defects in multiple nerves caused by avulsion amputation of the upper limb.

Wrist fusion in peripheral paralysis

In cases of paralysis of the upper limb, wrist fusion is useful in selected indications, especially when there are little to no tendon transfers available to restore finger function and wrist extension. Wrist fusion is particularly useful in the sequelae of brachial plexus lesions and in total paralysis of the radial nerve with hand drop and preserved wrist flexors. Numerous fusion techniques have been proposed. In cases of sequelae of brachial plexus lesions, locking of pronation-supination is associated with the wrist fusion. The use of anatomical plates has dropped the non-union and complication rates.

Brachial Plexus Injuries - Review of the Anatomy and the Treatment Options

Brachial plexus injuries are still challenging for every surgeon taking part in treating patients with BPI. Injuries of the brachial plexus can be divided into injuries of the upper trunk, extended upper trunk, injuries of the lower trunk and swinging hand where all of the roots are involved in this type of the injury. Brachial plexus can be divided in five anatomical sections from its roots to its terminal branches: roots, trunks, division, cords and terminal branches. Brachial plexus ends up as five terminal branches, responsible for upper limb innervation, musculocutaneous, median nerve, axillary nerve, radial and ulnar nerve. According to the findings from the preoperative investigation combined with clinically found functional deficit, the type of BPI will be confirmed and that is going to determine which surgical procedure, from variety of them (neurolysis, nerve graft, neurotization, arthrodesis, tendon transfer, free muscle transfer, bionic reconstruction) is appropriate for treating the patient.

Reoperation Rate and Indication for Reoperation after Free Functional Muscle Transfers in Traumatic Brachial Plexus Injury

Background

Free functional gracilis muscle transfers (FFGT) are an option for reconstruction after traumatic brachial plexus injury. Few studies report the rate of revision surgeries following free functional muscle transfers. We examined the reoperation rate and indication for reoperation after primary reconstruction of upper extremity function with a free gracilis transfer after brachial plexus injury.

Methods

From 2003-2016, we identified 25 patients who underwent a free functional gracilis muscle transfer for restoration of upper extremity function. We reviewed their medical charts to record patient, injury, and treatment characteristics. Indication for reoperation and reoperative procedure were also identified.

Results

Fourteen out of 25 patients (56%) had a reoperation after FFGT. Four flaps were re-explored for vascular compromise, but there were no flap failures. The majority of reoperations involved adjustment of tendon excursion (8/14) which demonstrated that tenolysis was the main procedure.

Conclusion

Despite promising results of free functional gracilis transfers, reoperation is relatively common and should be discussed with the patient as a preoperative strategy. Early exploration of vascular compromise may decrease the flap failure. Poor tendon excursion is a common unpredicted consequence after FFMT and is the main indication for reoperation.

Cost-Effectiveness Analysis Comparing Proximal Row Carpectomy and Four-Corner Arthrodesis

Background:

The optimal surgical treatment for scapholunate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) remains unclear. To inform clinical decision-makers, we conducted a cost-effectiveness analysis comparing proximal row carpectomy (PRC) and four-corner arthrodesis (FCA).

Methods:

A Markov microsimulation model was used to compare clinical outcomes, costs, and health utilities between PRC and FCA. The model used a 10-year time horizon and a 1-month cycle length, and it was evaluated from the societal perspective. Utilities and clinical parameters including transition probabilities for debridement for infection, removal of implants, conversion to total wrist arthrodesis, revision FCA, and revision total wrist arthrodesis were obtained from published literature. Timing of complications was estimated from the literature. Direct medical costs were derived from Medicare ambulatory surgical cost data, and indirect costs for missed work due to surgical procedures and complications were included. The effectiveness outcome was quality-adjusted life years (QALYs). Probabilistic sensitivity analysis and 1-way threshold analysis for utilities were performed.

Results:

In the base-case model, PRC dominated FCA (i.e., PRC had lower cost and greater effectiveness). The mean (and standard deviation) for the total cost and QALYs per patient were $30,970 ± $5,931 and 8.24 ± 1.28, respectively, for PRC and $44,526 ± $11,205 and 8.23 ± 1.26, respectively, for FCA. In the probabilistic sensitivity analysis, PRC dominated FCA in 57% of the 1 million iterations. The cost-effectiveness acceptability curve indicated that PRC is the most cost-effective strategy regardless of the willingness-to-pay threshold up to $100,000/QALY.

Conclusions:

PRC dominated FCA in the base-case analysis and in the probabilistic sensitivity analysis. These results suggest that PRC is the optimal strategy for Stage-I or II SLAC and for SNAC in patients ≥55 years of age.

Level of Evidence:

Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A Modified Surgical Technique for Minimally Invasive Arthroscopic Total Wrist Fusion

Background  Arthroscopic total wrist arthrodesis is a procedure with minimal violation of extensor compartments and less scar formation, compared with open wrist arthrodesis. In this paper, we would like to present our experience with a modified surgical technique for arthroscopic total wrist arthrodesis. Description of Technique  After an arthroscopic cartilage removal through radiocarpal and midcarpal portals, the operation is continued under fluoroscopic control. In this technique, four wires are inserted separately in four various directions (as described in the paper), followed by insertion of self-tapping cannulated screw, under fluoroscopic control. Patients and Methods  In this prospective study, a total of four patients underwent arthroscopic total wrist arthrodesis using our surgical technique within a period of 2 years. All four patients were followed for a minimum of 3 months for possible complications and functional outcome. Results  The results were satisfactory, and no complication was observed. All the patients had complete union after 12 weeks, and the fusion was radiographically complete in all cases by 12 weeks. All patients were happy with their functional outcomes. Conclusion  Using the described modified arthroscopic technique, we did four total wrist arthrodeses with minimal scar, no complication and acceptable functional results.

Nonspanning Total Wrist Arthrodesis with a Low-Profile Locking Plate

Purpose  This study aims to compare the outcomes and complications of our technique for nonspanning total wrist arthrodesis using a locking plate with the standard carpometacarpal spanning technique. Methods  A retrospective review of charts was performed to identify patients who underwent total wrist arthrodesis by the senior author (S.W.W.). We compared the outcomes of 15 cases of nonspanning wrist fusion with a 2.4/2.7 mm locking T plate to 11 cases of spanning wrist fusion with a 2.7/3.5 mm locking compression plate. Minimum follow-up was 3 months. Indications for fusion included rheumatoid arthritis, posttraumatic arthritis, Kienböck's disease, primary osteoarthritis, juvenile inflammatory arthropathy, psoriasis, brachial plexopathy, failed hemi or total wrist arthroplasty, failed four-corner fusion, and failed proximal row carpectomy. The primary outcome was fusion. Secondary outcomes included time to union, patient-rated wrist evaluation score, numerical rating scale pain score, grip strength, and complications. Results  All the wrists got fused. There were no significant differences in objective and subjective outcomes between cohorts. There were three complications (27%) in the spanning group, including tendon rupture and peri-implant fracture at the third metacarpal. This was compared with three complications (20%) in the nonspanning group, consisting of hardware removal. Discussion  We achieved similar fusion rates employing both spanning and nonspanning total wrist arthrodesis techniques, without necessitating carpometacarpal arthrodesis in the latter. Complications associated with our method were comparably less severe than those reported in the literature. We advocate nonspanning arthrodesis as an alternative method for total wrist fusion with a high union rate and minimal risk of complications at the carpometacarpal joint. Level of Evidence  Therapeutic level IV.

Restoration of active pick-up function in patients with total brachial plexus avulsion injuries

We designed multiple nerve transfers in one surgery to restore active pick-up function in patients with total brachial plexus avulsion injuries. Forty patients with total brachial plexus avulsion injuries first underwent multiple nerve transfers. These included transfer of the accessory nerve onto the suprascapular nerve to recover shoulder abduction, contralateral C7 nerve onto the lower trunk via the modified prespinal route with direct coaptation to restore lower trunk function and onto the musculocutaneous nerve with interpositional bridging by medial antebrachial cutaneous nerve arising from lower trunk to restore elbow flexion, and the phrenic nerve onto the posterior division of lower trunk to recover elbow and finger extension. At least three years after surgery, the patients who had a meaningful recovery were selected to perform secondary reconstruction to restore active pick-up function. Active pick-up function was successfully restored in ten patients after they underwent multiple nerve transfers combined with additional secondary functional hand reconstructions.

LEVEL OF EVIDENCE

IV.

Free Functional Muscle Transfers to Restore Upper Extremity Function

Free functional muscle transfer provides an option for functional restoration when nerve reconstruction and tendon transfers are not feasible. To ensure a successful outcome, many factors need to be optimized, including proper patient selection, timing of intervention, donor muscle and motor nerve selection, optimal microneurovascular technique and tension setting, proper postoperative management, and appropriate rehabilitation. Functional outcomes of various applications to the upper extremity and the authors' algorithm for the use of free functional muscle transfer are also included in this article.

The role of elective amputation in patients with traumatic brachial plexus injury

BACKGROUND AND AIM

Despite undergoing complex brachial plexus, surgical reconstructions, and rehabilitation, some patients request an elective amputation. This study evaluates the role of elective amputation after brachial plexus injury.

METHODS

A retrospective chart review was performed for all the 2140 patients with brachial plexus injuries treated with elective amputation between 1999 and 2012 at a single institution. Analysis was conducted on the potential predisposing factors for amputation, amputation level, and postamputation complications. Patients were evaluated using pre- and postamputation Disabilities of the Shoulder, Arm, and hand scores in addition to visual analog pain scores.

RESULTS

The following three conditions were observed in all nine patients who requested an elective amputation: (1) Pan-plexus injury; (2) non-recovery (mid-humeral amputation) or elbow flexion recovery only (forearm amputation) 1 year after all other surgical options were performed; and (3) at least one chronic complication (chronic infection, nonunion fractures, full-thickness burns, chronic neck pain with arm weight, etc.). Pain improvement was found in five patients. Subjective patient assessments and visual analog pain scores before and after amputation did not show a statistically significant improvement in Disabilities of the Shoulder, Arm, and Hand Scores. However, four patients reported that their shoulder pain felt "better" than it did before the amputation, and two patients indicated they were completely cured of chronic pain after surgery.

CONCLUSIONS

Elective amputation after brachial plexus injury should be considered as an option in the above circumstances. When the informed and educated decision is made, patients can have satisfactory outcomes regarding amputation.

Wrist, first carpometacarpal joint, and thumb interphalangeal joint arthrodesis in patients with brachial plexus injuries

PURPOSE

Wrist arthrodesis, first carpometacarpal joint arthrodesis, and thumb interphalangeal joint arthrodesis can be used in conjunction with other reconstructive measures to improve function and grasp in patients with complete brachial plexus injuries. This study evaluates wrist arthrodesis, first carpometacarpal joint arthrodesis, and thumb interphalangeal joint arthrodesis as measured by fusion rate, complications, and clinical outcomes.

METHODS

A retrospective chart review was performed for 24 skeletally mature patients with brachial plexus injuries treated with wrist arthrodesis by a dorsal plating technique, first carpometacarpal joint arthrodesis by staples, and thumb interphalangeal joint arthrodesis by a tension band wiring technique. Nineteen patients were subjectively evaluated using prearthrodesis and postarthrodesis Disabilities of the Shoulder, Arm, and Hand scores, visual analog pain scores, and a visual analog scale assessing appearance, function, hygiene, ease of daily care, pain, and overall satisfaction.

RESULTS

There was 100% union rate with 1 postarthrodesis complication. One patient required wrist fusion plate removal because of painful hardware. Subjective patient assessments showed a statistically significant (P < .001) improvement in Disabilities of the Shoulder, Arm, and Hand scores (from 51 to 28) and pain scores (from 5.3 to 3.2) before and after arthrodeses. The visual analog questionnaire results revealed improvements in appearance, function, daily cares, hygiene, pain, and satisfaction.

CONCLUSIONS

Wrist arthrodesis, first carpometacarpal joint arthrodesis, and thumb interphalangeal joint arthrodesis had high union rates with minimal complications. Patients benefited from the improved function of their upper extremities and were satisfied with the surgery. The use of wrist, first carpometacarpal joint, and thumb interphalangeal joint arthrodeses in combination should be considered one of the reconstructive possibilities for patients with complete or nearly complete brachial plexus injuries.