Posterior Deltoid Function After Transfer of Branch to the Long Head Triceps Brachii of the Radial Nerve to the Anterior Branch of the Axillary Nerve

PURPOSE

The aim of this study was to evaluate the function of the posterior part of the deltoid after nerve transfer of the long head triceps branch of the radial nerve to the anterior branch of the axillary nerve in patients with an upper brachial plexus injury or isolated axillary nerve injury.

METHODS

We retrospectively reviewed 26 patients diagnosed with an upper brachial plexus injury or isolated axillary nerve injury who underwent nerve transfer of the long head triceps muscle branch of the radial nerve to the anterior branch of the axillary nerve in our institute between 2012 and 2017. Data on age, sex, the mechanism of injury, the pattern of injury, and operative treatment were collected from medical records. Preoperative and postoperative clinical examinations, including motor powers of shoulder abduction and extension according to Medical Research Council grading, were evaluated. At a minimum of 2 years after the operation, we evaluated the recovery of the posterior deltoid function using the swallow-tail test.

RESULTS

Twenty-two patients (84.6%) had recovery of posterior deltoid function confirmed by the swallow-tail test. There were 23 patients (88.5%) who achieved at least Medical Research Council grade 4 of shoulder abduction.

CONCLUSIONS

Nerve transfer from the branch to the long head triceps to the anterior branch of the axillary nerve is an effective technique for restoring deltoid function in an upper brachial plexus injury or isolated axillary nerve injury. This technique can provide shoulder abduction and shoulder extension, which are the functions of the posterior deltoid muscle.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Dorsoradial Ligament Reconstruction in Trapeziometacarpal Joint Arthritis

BACKGROUND

The main purpose of the study is to present the alternative novel surgical technique in treating patients with trapeziometacarpal (TMC) joint arthritis using dorsoradial ligament (DRL) reconstruction technique and report the clinical outcomes.

METHODS

Patients who were diagnosed with TMC joint arthritis and underwent DRL reconstruction were evaluated. Visual analog pain score; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; grip, tip pinch, tripod pinch, and key pinch strengths along with range of motion of the thumb; and Kapandji score were recorded in the preoperative period and at follow-up. Stress examination was also performed under a fluoroscope.

RESULTS

Eleven patients were included in the study. Median follow-up time was 13 months. At follow-up, postoperative visual analog scale and QuickDASH score improved in all patients. Grip, tip pinch, tripod pinch, and key pinch strengths also improved. The range of motion and Kapandji score were slightly improved compared with the preoperative period except for the thumb metacarpophalangeal flexion. Two patients had numbness at the thumb and spontaneously recovered after 3 months.

CONCLUSIONS

According to recent evidence which proposed the importance of DRL in TMC joint stability, our DRL reconstruction technique may be an alternative treatment in treating patients presented with TMC joint arthritis. Further study with a longer follow-up period is needed.

The Intercostal Nerves Transfer to the Radial Nerve Branch to the Long Head Triceps Muscle: Influencing Factor and Outcome of 55 Cases

PURPOSE

The objective of this study was to report the functional outcomes and factors affecting the result of intercostal nerves transfer to the radial nerve branch to the long head triceps muscle for restoration of elbow extension in patients with total brachial plexus palsy or C5 to C7 palsy with the loss of triceps muscle function.

METHODS

Fifty-five patients with total brachial plexus palsy or C5 to C7 palsy with no triceps muscle function had a reconstruction of elbow extension by transferring the third to fifth intercostal nerves to the radial nerve branch to the long head triceps muscle. The functional outcomes determined by the Medical Research Council grading were evaluated. Factors influencing the outcomes were determined using logistic regression analysis.

RESULTS

At the follow-up of at least 2 years, 36 patients (65%) had antigravity motor function (Medical Research Council grade, ≥3). Multivariable logistic regression analysis showed that the body mass index, time to surgery, and injury of the dominant limb were associated with the outcome.

CONCLUSIONS

The third to fifth intercostal nerves transfer to the radial nerve branch to the long head triceps muscle is an effective procedure to restore elbow extension. We would recommend using 3 intercostal nerves without grafts; in cases of nerve root avulsion in which there is no chance of spontaneous recovery, early surgery should be considered.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Painful Snapping of Thumb Caused by Osteochondroma of Trapezium

Osteochondroma is the most common benign bone tumor. Lesions occurring at the carpal bones are extremely rare. There are very few cases of osteochondroma at the trapezium had been reported in the English literature. We reported a 47-year-old patient with an osteochondroma of the left trapezium presented with painful snapping of abductor pollicis longus tendon.

Surgical anatomy of the dorsal cutaneous branch of the ulnar nerve and its clinical significance in surgery at the ulnar side of the wrist

The dorsal cutaneous branch of the ulnar nerve can be easily injured during surgery at the ulnar side of the wrist. We sought to identify the surgical anatomy, the pathway around the ulnar styloid process and the safe zone of the dorsal cutaneous branch of the ulnar nerve. In 44 forearm dissections, we found that the dorsal cutaneous branch of the ulnar nerve originated at a median distance of 6.8 cm proximal to the tip of the ulnar styloid. We classified the crossing pattern of the dorsal cutaneous branch of the ulnar nerve at a vertical axis into three types. The most common type featured the dorsal cutaneous branch of the ulnar nerve crossing the vertical axis at a median distance of 10.0 mm distal to the tip of the ulnar styloid. In 14% of specimens, the dorsal cutaneous branch of the ulnar nerve crossed the vertical axis at the level of the tip of the ulnar styloid. By mapping the course of the nerve using a Cartesian coordinate system, it was found that the areas located proximal and palmar to the tip of the ulnar styloid had a very high density of dorsal cutaneous branches of the ulnar nerve. We were unable to establish a safe zone. We recommend identifying the dorsal cutaneous branch of the ulnar nerve in every patient undergoing surgery at the ulnar side of the wrist.

Simultaneous Phrenic and Intercostal Nerves Transfer for Elbow Flexion and Extension in Total Brachial Plexus Root Avulsion Injury

BACKGROUND

To report the results of restoring the elbow flexion and extension in patients with total brachial root avulsion injuries by simultaneous transfer of the phrenic nerve to the nerve to the biceps and three intercostal nerves to the nerve of the long head of the triceps.

METHODS

Ten patients with total brachial root avulsion injuries underwent the spinal accessory nerve transfer to the suprascapular nerve for shoulder reconstruction. Simultaneous transfer of the phrenic nerve to the nerve to the biceps via the sural nerve graft and three intercostal nerves to the nerve of the long head of the triceps was done for restoration of the elbow flexion and extension. Trunk flexion exercise program was used for all patients postoperatively. The mean follow up period was 36 months.

RESULTS

For elbow flexion, there were two M4, seven M3, and one M1. For elbow extension, there were three M4, four M3, two M2, and one M1. No patient demonstrated a respiratory problem clinically postoperatively. The average FVC% decreased to 61% of the predicted value at 24 months after surgery.

CONCLUSIONS

The simultaneous nerve transfer using the phrenic nerve to the nerve to the biceps and 3 intercostal nerves to the nerve of the long head of the triceps with postoperative trunk flexion exercise provide a comparable result for restoration of elbow function in total brachial plexus root avulsion injury. The patients who appear to have a respiratory problem and are unable to comply with the post-operative respiratory muscles training should be contraindicated for this simultaneous transfer.

Polyester tape scapulopexy for chronic upper extremity brachial plexus injury

PURPOSE

To report the results of scapular stabilization for winging in patients with chronic upper brachial plexus injury.

METHODS

Eight patients, mean age 36 years, who had a winged scapula after successful restoration of major shoulder function by nerve transfer underwent scapular stabilization to the ribcage using polyester tape. The follow-up period ranged from 24 to 40 months (mean, 38 mo). Data collection included radiographic analysis, active range of motion measurement, University of California Los Angeles shoulder score, and visual analog scale pain score.

RESULTS

All patients had clinical improvement with resolution of scapular winging. Five patients had no winging and 3 had mild winging after the surgery. Mean active forward flexion increased from 101° preoperatively to 127° postoperatively. Mean active shoulder abduction increased from 91° preoperatively to 121° postoperatively. Mean University of California Los Angeles shoulder score improved from 17 to 27 and mean visual analog scale pain score improved from 6.1 to 0.7. In addition, mean lateral deviated angle increased from 4° from neutral preoperatively to 9° at the last follow-up. All patients reported satisfaction with postoperative appearance.

CONCLUSIONS

Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Proximal ulnar stump stability after using the pronator quadratus muscle transfer combined with the Suavé-Kapandji procedure in rheumatoid wrist

The pronator quadratus muscle transfer combined with the Sauvé-Kapandji procedure was used to treat the distal radioulnar joint disorder in ten rheumatoid wrists for prevention against instability of the proximal ulnar stump. All patients were female with a mean age of 46.6 years. The mean follow-up time was 24.2 months. Postoperatively, supination increased in all patients with a mean of 50 degrees. Pain decreased significantly and none complained of prominence of the proximal ulnar stump in normal pronated position and during a tight grip. The wrist radiographs of both coronal and sagittal planes in normal and stress fisting views were used to evaluate the postoperative static and physiologic loaded stability of the proximal ulnar stump. It had shown this procedure provided good static proximal ulnar stump stability in both coronal and sagittal planes. However, in physiologic loaded condition, it was able to provide stability only in the sagittal plane.

Surgical anatomy of the axillary nerve branches to the deltoid muscle

Variations in the innervation of the posterior deltoid muscle by the anterior branch of the axillary nerve have been reported. The objective of this study is to clarify the anatomy of the axillary nerve branches to the deltoid muscle. One hundred and twenty-nine arms (68 right and 61 left) from 88 embalmed cadavers (83 male and 46 female) were included in the study. The anterior and posterior branches of the axillary nerve were identified and their lengths were measured from the point of emergence from the axillary nerve to their terminations in the deltoid muscle. In all cases, the axillary nerves split into two branches (anterior and posterior) within the quadrangular space and none split within the deltoid muscle. In all specimens, the anterior and middle parts of the deltoid muscle received their nerve supplies from the anterior branch of the axillary nerve. The posterior part of the deltoid muscle was supplied only by the anterior branch of the axillary nerve in 2.3% of the specimens, from the posterior branch in 8.5%, and from both branches in 89.1%. There were two sub-branches of the anterior branch in 4.7% of the specimens. The anterior branch of the axillary nerve supplied not only the anterior and middle parts of the deltoid muscle but also the posterior part in most cases (91.5%).

Simultaneous intercostal nerve transfers to deltoid and triceps muscle through the posterior approach

PURPOSE

This study reports the results of restoring the deltoid and triceps functions in patients with C5, C6, and C7 root avulsion injuries by simultaneously transferring 4 intercostal nerves to the anterior axillary nerve and the nerve to the long head of the triceps through the posterior approach.

METHODS

Nine patients with C5, C6, and C7 root avulsion injuries underwent spinal accessory nerve transfer to the suprascapular nerve combined with transfer of the third and fourth intercostal nerves to the anterior axillary nerve for shoulder reconstruction. Simultaneous transfer of the fifth and sixth intercostal nerves to the radial nerve branch of the triceps was done to restore elbow extension.

RESULTS

For shoulder function, 8 patients had M4 recovery and 1 patient had M2 recovery. Average shoulder abduction and external rotation were 69° and 42°, respectively. For elbow extension, 3 patients achieved M3 recovery, 5 patients had M2 recovery, and 1 patient had M1 recovery.

CONCLUSIONS

Reconstruction of 2 muscles with intercostal nerves is possible when both muscles act synergistically, such as shoulder abduction and elbow extension. Two intercostal nerves are adequate to transfer for deltoid reconstruction but not enough for elbow extension against gravity.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

End-to-side radial sensory to median nerve transfer to restore sensation and relieve pain in C5 and C6 nerve root avulsion

PURPOSE

To report the results of end-to-side nerve transfer of the superficial radial nerve into the median nerve for restoration of sensation and pain relief at the dorsal radial aspect of the hand in C5 and C6 root avulsion.

METHODS

Eight patients with a mean age of 32 years, with paresthesia and pain at the dorsal radial aspect of the hand due to upper brachial plexus injuries, had end-to-side nerve transfer of the superficial radial nerve into the ulnovolar part of the median nerve. Five patients had S0 and 3 patients had S1 sensory evaluation at the dorsal radial aspect of the affected hand. We evaluated patients for pain using a visual analog scale. We assessed sensory recovery with the Semmes-Weinstein monofilament test and British Medical Research Score, respectively. The follow-up period ranged from 24 to 36 months (average, 28 mo).

RESULTS

Six patients had S2 and 2 patients had S3. All patients perceived at least one number lower of the Semmes-Weinstein filament in the dorsal radial aspect of the affected hand compared with the preoperative status. The best result was perception of the 3.61 filament in 2 patients. No downgrading of the donor nerve was observed after surgery. All patients had relief of pain 2 weeks after surgery, and the pain decreased dramatically at the last follow-up.

CONCLUSIONS

This method is a reliable, effective, and simple procedure. We recommend this sensory nerve transfer as an additional procedure to the combined motor nerve transfers to relieve pain and restore sensation in the dorsal radial aspect of the hand in patients who have C5 and C6 root avulsion.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Bilateral congenital hypoplasia of the extensor tendons of the hand: a case report

Congenital hypoplasia of the extensor tendons, which is defined as a congenital anomaly of the hand involving the extensor mechanism, is a rare condition and there are few previous reports in literature. We reported a case of bilateral congenital hypoplasia of the extensor tendons in a 12-year-old boy who presented with inability to extend his middle and ring fingers treated by the flexor carpi radialis tendon transfers.

Restoration of winged scapula in upper arm type brachial plexus injury: anatomic feasibility

BACKGROUND

The patients who have C5-C6 root avulsion in brachial plexus injury, suffered from loss of elbow flexion, shoulder abduction and winged scapula. The purpose of study is to provide anatomic feasibility of thoracodorsal nerve (medial and lateral branches) and long thoracic nerve for restoration of the shoulder function caused by winged scapula.

MATERIAL AND METHOD

To study the length of thoracodorsal nerve and long thoracic nerve from the apex of the posterior axillary line to the insertion of the latissimus dorsi muscle and the serratus anterior muscle respectively, 10 fresh cadavers were dissected. The distance between the thoracodorsal nerve and long thoracic nerve, and the numbers of fascicles and axon were measured by histomorphometry. We transferred the lateral branch of the thoracodorsal nerve to the long thoracic nerve in order to restore the serratus anterior muscle function.

RESULTS

The mean length of the thoracodorsal nerve from apex of posterior axillary line to bifurcation before separation to medial and lateral branches was 31.5 mm. The average length of the thoracodorsal nerve and long thoracic nerve from bifurcation to the insertion of the latissimus dorsi muscle and the serratus anterior muscle were 10.3, 82.2, and 99.5 mm, respectively. The distance between the lateral branch of the thoracodorsal nerve and long thoracic nerve was 33.4 mm. The mean number of myelinated nerve fiber of the thoracodorsal nerve medial and lateral branches and long thoracic nerve were 973.8, 1843.3 and 1135.3 axons, respectively.

CONCLUSION

The anatomic study of the thoracodorsal nerve and long thoracic nerve showed that the lateral branch of the thoracodorsal nerve is proper in the length and numbers of axon to transfer to the long thoracic nerve for restoration of shoulder function caused by the winged scapula.

Nerve transfer for wrist extension using nerve to flexor digitorum superficialis in cervical 5, 6, and 7 root avulsions: anatomic study and report of two cases

PURPOSE

To evaluate the feasibility of restoring wrist extension in patients with complete cervical root 5 (C5), 6, and 7 avulsion injuries by transferring the most proximal branch of the median nerve that innervates flexor digitorum superficialis (FDS) muscle (proximal FDS branch) to the branch of the radial nerve that innervates extensor carpi radialis brevis (ECRB) muscle (ECRB branch) in an anatomic study and 2 case reports.

METHODS

The study was performed on 10 fresh cadavers. The nerve branches of the median nerve and the radial nerve were measured for length, diameter, and sites of origin of their nerve branches. The nerve branches of the median nerve, the posterior interosseous nerve, and the ECRB branch of the radial nerve were processed for histomorphometric evaluation. Using image analysis software, we took all histomorphometric measurements of the nerve sections. Based on this anatomical study, the proximal FDS branch was transferred directly to the ECRB branch without nerve graft in 2 patients.

RESULTS

The average distance from the origin of nerve branches to the interepicondylar line was 3.5 and 2.3 cm, respectively, for the proximal FDS and ECRB branches. The average length of the proximal FDS branch and ECRB branch was 2.8 and 3.3 cm, respectively. The average number of myelinated nerve fibers of the proximal FDS branch and ECRB branch was 983 and 2,797, respectively. At 2 years' follow-up, preliminary clinical results demonstrated that wrist extension had gained strength against resistance (grade M4). The arc of motion for wrist extension was 30 degrees in the first patient and 70 degrees in the second one. Useful functional recovery was achieved and classified as good result in both cases.

CONCLUSIONS

The anatomic study and 2 reported results supports our hypothesis that transfer of the proximal FDS branch of median nerve to the ECRB branch of radial nerve could be an alternative method for reconstructiing wrist extension in C5, 6, and 7 avulsion injuries.

Nerve transfer to serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus root avulsions

PURPOSE

To report the results of nerve transfer to the serratus anterior muscle using the thoracodorsal nerve for winged scapula in C5 and C6 brachial plexus avulsion.

METHODS

Five patients with a mean age of 27 years with loss of shoulder abduction due to upper brachial plexus injuries and with winged scapula had nerve transfer using 1 branch (1 medial and 4 lateral) of the thoracodorsal nerve to the long thoracic nerve. The spinal accessory nerve and the nerve to the long head of the triceps were used simultaneously for nerve transfer to the suprascapular nerve and the axillary nerve, respectively. The follow-up period ranged from 24 to 33 months (mean, 28 months).

RESULTS

All patients recovered serratus anterior muscle function. Two patients had no winged scapula, whereas 3 patients had mild winged scapula after the surgery at the last follow-up evaluation. The result was excellent for 2 patients, good for 2 patients, and fair for 1 patient. The mean arcs of motion of shoulder abduction and external rotation were 134 degrees and 124 degrees , respectively. No notable weakness of shoulder adduction was observed.

CONCLUSIONS

Use of the branch of the thoracodorsal nerve ensured adequate return function of the serratus anterior muscle by decreasing or correcting winged scapula in upper brachial plexus injury. We recommend nerve transfer for winged scapula for achieving optimum shoulder function.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Cross-cultural adaptation to the Thai language of the neuropathic pain diagnostic questionnaire (DN4)

OBJECTIVE

To cross-culturally adapt the neuropathic pain diagnostic questionnaire (DN4) to Thai language

MATERIAL AND METHOD

Phase 1: Forward and backward translation followed by assessment of semantic equivalence. Phase 2: Testing of the questionnaire in 30 neuropathic pain patients who were seen and diagnosed by experts, followed by modifications to produce a final version.

RESULTS

All the Thai translated pain descriptors except 'tingling' got high percentages of understanding among neuropathic pain patients in the first round of testing. After some adaptation of the Thai word for 'tingling' had been made, the new translated word was retested, and all subjects doing the retest understood the word very well.

CONCLUSION

The Thai DN4 questionnaire was systematically translated and validated. This offers a simple Thai neuropathic pain diagnostic tool for clinical use.

Necrotising fasciitis causing compartment syndrome of the forearm and septic shock due to Vibrio vulnificus: a case report

Compartment syndrome caused by necrotising fasciitis has rarely been described. We report a case of systemic Vibrio vulnificus necrotising fasciitis presented with compartmental syndrome of the forearm and septic shock. The patient was treated with systemic antibiotic treatment and urgent surgical decompression followed by multiple necrotic tissue debridements. The patient recovered with some limited motion of the hand function. Prompt recognition and immediate treatment with antibiotics and surgical intervention are essential.

Nerve transfer to deltoid muscle using the intercostal nerves through the posterior approach: an anatomic study and two case reports

PURPOSE

To evaluate the feasibility of restoring the deltoid function in patients with C5 through C7 root avulsion injuries by transferring 2 intercostal nerves to the anterior branch of the axillary nerve through a posterior approach. The preliminary results of the clinical application of this procedure also are reported.

METHODS

The study was performed on 10 fresh cadavers. The lengths of the third, fourth, and fifth intercostal nerves from the costochondral junction to the midaxillary line were recorded. The distance from the pivot point at the midaxillary line to the anterior branch of the axillary nerve was recorded as the tunnel length. All histomorphometric measurements of the axon number were recorded. Based on the anatomic study, the fourth and fifth intercostal nerves were transferred directly to the anterior branch of the axillary nerve in 2 patients.

RESULTS

The average distances from the costochondral junction of the third, fourth, and fifth intercostal nerves to the pivot points were 12, 15, and 16 cm, respectively. The average tunnel distances of the third, fourth, and fifth intercostal nerves were 11, 13, and 15 cm, respectively. The average numbers of myelinated nerve fibers of the third, fourth, and fifth intercostal nerves were 742, 830, and 1,353, respectively. At the 2-year follow-up evaluation the preliminary clinical results showed that the deltoid recovered against resistance (M4). The range of motion for shoulder abduction and external rotation were both 95 degrees in the first case and 105 degrees and 95 degrees , respectively, in the second case. Useful functional recovery was achieved and classified as a good result in both patients.

CONCLUSIONS

This anatomic study with 2 case reports supports the idea that transfer of 2 intercostal nerves to the anterior branch of the axillary nerve through the posterior approach could be an alternative method for reconstruction of the deltoid muscle in C5 through C7 root avulsion injuries.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Combined nerve transfers for C5 and C6 brachial plexus avulsion injury

PURPOSE

To report the results of combined nerve transfer in C5 and C6 brachial plexus avulsion injury.

METHODS

Fifteen patients had nerve transfers: spinal accessory nerve to the suprascapular nerve, a part of the ulnar nerve to the biceps motor branch, and the nerve to the long head of the triceps to the anterior branch of the axillary nerve. Patients were evaluated with regard to elbow flexion, shoulder abduction, and shoulder external rotation.

RESULTS

All patients had recovered full elbow flexion: 13 scored M4 and 2 scored M3. Thirteen of the 15 patients obtained good results. The weight the patients could lift ranged from 0 to 7 kg. All patients had recovery of the deltoid function: 13 scored M4 and 2 scored M3. All 15 patients achieved useful functional recovery. Ten patients experienced excellent recoveries and 5 were classified as having good results. The mean shoulder abduction was 115 degrees . Shoulder external rotation strength was scored as M4 in 9 patients, M3 in 4 patients, and M2 in 2 patients. The range of motion of external rotation that was measured from full internal rotation averaged 97 degrees . No clinical donor nerve deficits were observed.

CONCLUSIONS

We recommend combined nerve transfers for C5 and C6 avulsion root injuries. These nerve transfers have the advantage of a quick recovery time as a result of the short regeneration distance without nerve graft.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part II: a report of 7 cases

PURPOSE

This study reports the results of nerve transfer to the deltoid muscle using the nerve to the long head of the triceps.

METHODS

Seven patients with an average age of 25 years with loss of shoulder abduction secondary to upper brachial plexus injuries had nerve transfer using the nerve to the long head of the triceps to the anterior branch(es) of the axillary nerve through the posterior approach. The spinal accessory nerve was used simultaneously for nerve transfer to the suprascapular nerve. The follow-up period ranged from 18 to 28 months (average, 20 mo).

RESULTS

All patients recovered deltoid power against resistance (M4) at the last follow-up evaluation. Useful functional recovery was achieved in all 7 patients; 5 had excellent recoveries and 2 had good results. The average shoulder abduction was 124 degrees. No notable weakness of elbow extension was observed.

CONCLUSIONS

This method is a reliable and effective procedure for deltoid reconstruction in brachial plexus injury (upper-arm type) and should be combined with spinal accessory nerve transfer to the suprascapular nerve to obtain good shoulder abduction.

Nerve transfer to deltoid muscle using the nerve to the long head of the triceps, part I: an anatomic feasibility study

PURPOSE

To experimentally evaluate the feasibility of restoring the motor function of the deltoid muscle in patients with complete C5-C6 root injury (upper brachial plexus injury) by transferring the nerve to the long head of the triceps to the anterior branch of the axillary nerve through a posterior approach.

METHODS

The study was performed on shoulder girdles of 36 formalin-embalmed cadavers. The number, diameter, and length of the branches of the axillary nerve at the level of the quadrilateral space were noted. The length and diameter of the nerves to the long head and to the lateral head of triceps at the level of triangular space were recorded. The distances from the acromion angle to the bifurcation of the anterior branch of the axillary nerve, to the origins of the nerve to the long head, and to the origin of the lateral head of the triceps were recorded as well. Nerve biopsy specimens of the axillary nerve and the nerve to the long head of the triceps were obtained from 6 fresh cadavers for histomorphometric evaluation.

RESULTS

The average length of the anterior branch of the axillary nerve in this study, measured from the quadrilateral space to the innervating site, was 44.5 mm (range, 26-62 mm), and the average length of the nerve to the long head of triceps, measured from its origin to the innervating site, was 68.5 mm (range, 30-69 mm). The average diameter of the anterior branches of the axillary nerve and the nerve to the long head of the triceps were 2.1 and 1.1 mm, respectively. The average number of axon fibers in the anterior branch of the axillary nerve was 2,704 and in the nerve to the long head of the triceps was 1,233.

CONCLUSIONS

Using the acromial angle as the landmark, the combined length of the two 2 nerves was longer than the distance between them. The diameter, the number of axons, and the anatomic proximity of the nerve to the long head of the triceps make it a potential source for reinnervation of the anterior branch of the axillary nerve by direct nerve transfer without nerve grafting through posterior approach for the management of upper brachial plexus injuries.

Penetrating injury to the terminal branches of the posterior interosseous nerve with nerve grafting

We report two cases of penetrating injuries to the terminal branches of the posterior interosseous nerve in the forearm. Repair using nerve grafts in both cases were followed by complete recovery.

Primary vascularized distal radius bone graft for nonunion of the scaphoid

A vascularized bone graft from the dorsoradial aspect of the distal radius was used with internal fixation to treat nonunion of the scaphoid in ten patients who had not received any previous surgical treatment. Five cases were classified as Lichtman type I and five as type II. The average age was 30 years (range, 18-40 years). Associated avascular necrosis was observed in five cases. Postoperatively pain was relieved and union was achieved in all cases. The mean time to union was 6.5 weeks. Range of motion, grip strength and pinch strength were also restored satisfactorily. These results suggest that this vascularized bone graft should be used as the primary procedure in Lichtman type I and II of scaphoid nonunions, regardless of the presence of avascular necrosis of the proximal pole.

Congenital pseudarthrosis of the forearm treated by free vascularized fibular graft: a report of three cases and a review of the literature

Congenital pseudarthrosis of the forearm is a rare condition; approximately 60 cases have been reported in the English literature. We report 3 patients treated by wide excision of the pseudarthrosis and free vascularized fibular grafting. The pseudarthrosis involved the radius in 1 patient and the ulna in 2. Neurofibromatosis was present in 2 patients. The technical problems encountered during the procedures included preservation of the distal epiphysis and attaining stable fixation of the fibular graft without damaging its vascular supply. A review of 15 previously reported patients treated by free vascularized fibular grafting showed that this procedure is excellent in the treatment of congenital pseudarthrosis of the forearm and that the result is consistently reproducible.

Nerve transfer to biceps muscle using a part of the ulnar nerve in brachial plexus injury (upper arm type): a report of 32 cases

Thirty-two patients with absent elbow flexion secondary to brachial plexus injury underwent nerve transfer using 1 or 2 fascicles of the ulnar nerve to the motor branch of the biceps muscle. Twenty-six patients had root avulsion injury of C5 and C6; 4 had root avulsion injury of C5, C6, and C7; and 2 had lateral and posterior cord injury with distal injury of the musculocutaneous nerve. The follow-up period ranged from 11 to 40 months (average, 18 months). Thirty patients had biceps strength of M4 (flexion power ranged from 0.5 to 7 kg) and 1 had biceps strength of M3. All but 1 patient demonstrated signs of recovery of the biceps muscle. No notable impairment of hand function was observed.

Anatomy and internal topography of the musculocutaneous nerve: the nerves to the biceps and brachialis muscle

One hundred twelve musculocutaneous nerves from 56 cadavers were examined to determine branching patterns of innervation and internal neurotopography. There were 3 distinct types of branching patterns for biceps innervation: in 62%, there was 1 branch only; in 33%, 2 branches; and in 5%, 3 branches. The origin of the first branch averaged 130 mm from the acromion regardless of branching type. The maximum distance between the first and second branch was 53 mm. In 92%, there was only 1 branch to the brachialis muscle. It always emerged from the main trunk distal to the nerve to the biceps and averaged 170 mm from the acromion. Internal topography was studied from 1-mm-thick serial sections of the musculocutaneous nerve in 5 fresh cadaver arms. The group of fasciculi of the nerve to the biceps, the nerve to the brachialis, and the lateral cutaneous nerve of the forearm were constantly located from lateral to medial. The fasciculi of the nerve to the biceps traveled proximally in the musculocutaneous nerve for an average distance of 63 mm.

Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases

Four patients with C5-C6 root avulsion after brachial plexus injury were treated with a transfer of part of a normal functioning nerve in the arm to the motor nerve of the biceps. Ten percent of the bulk of the ulnar nerve was harvested for a suture directly to the motor nerve of the biceps with no significant impairment of hand function.