Elective brachial plexus decompression in neurogenic thoracic outlet syndrome.

We aimed to evaluate functional outcome following elective brachial plexus decompression by compressive fibrous band resection and limited on-demand bone abnormality resection in patients with neurogenic thoracic outlet syndrome (N-TOS). A retrospective continuous observational study was conducted in 17 patients (15 women and 2 men), with a mean age of 42 years, operated on between 2013 and 2021. Twenty brachial plexus decompressions were performed, for 13 objective and 7 subjective N-TOSs, including 3 recurrent N-TOSs. At last follow-up, outcomes were evaluated in terms of residual pain, paresthesia and hand motor deficit, plus patient-reported assessment and Quick-DASH functional scoring. No postoperative complications occurred. At a median follow-up of 12 months (range 6-48 months), complete pain relief and paresthesia resolution were found in 11/15 and 9/14 cases, respectively. All patients reported that their symptoms had improved. In contrast, hand muscle atrophy persisted in all cases (n = 11). Sensorimotor recovery seemed to be poorer and mean Quick-DASH score better in objective than subjective N-TOS patients. Elective brachial plexus decompression seemed to be a safe procedure, providing constant improvement in subjective symptoms related to lower trunk irritation. However, nerve release did not provide hand muscle recovery in patients with objective N-TOS. LEVEL OF EVIDENCE: IV.

Chondrodesis of the wrist in children with severe paralytic hand deformities.

We examined the anatomical and clinical results of a new wrist subphyseal arthrodesis method called chondrodesis, which relies on resorbable suture-bone fixation for children with severe paralytic hand deformities and does not require fixation devices or bone grafting. Four children's wrists underwent the procedure, resulting in three successful wrist bone fusions. The wrists were stabilized by joint fusion in 4-5 months in good positions, ranging from neutral to extension 15°, while still allowing the forearm to keep growing since the radial growth plate remained open as of the last follow-up. The procedure improved hand function (House score, Raimondi score) and appearance. It also increased control over gripping motions with the operated hand, and even restored key pinch ability in one of the patients. The youngest patient was not able to achieve bone fusion at the key sites and will need further corrective procedures at a later and more optimal age. This novel procedure is appealing because of its technical reproducibility, low cost, encouraging outcomes, ease of rehabilitation, and because it spares the physeal cartilage.

Surgical strategy in extensive proximal brachial plexus palsies.

PURPOSE: To describe and assess an overall surgical strategy addressing extensive proximal brachial plexus injuries (BPI). METHODS: Forty-five consecutive patients' charts with C5-C6-C7 and C5-C6-C7-C8 BPI were reviewed. Primary procedures were nerve transfers to restore elbow function and grafts to restore shoulder function when a cervical root was available; when nerve surgery was not possible or had failed, tendon transfers were conducted at the elbow while addressing shoulder function with glenohumeral arthrodesis or humeral osteotomy. Tendon transfers were used to restore finger extension. RESULTS: Forty-one patients underwent elbow flexion reanimation: thirty-eight had nerve transfers and eight received tendon transfers, including five cases secondary to nerve surgery failure; grade-3 strength or greater was reached in thirty-seven cases (90%). Twenty-nine patients had nerve transfers to restore elbow extension: twenty-five recovered grade-3 or grade-4 strength (86%). Forty-one patients underwent shoulder surgery: fourteen had nerve surgery and thirty-one received palliative procedures, including four cases secondary to nerve surgery failure; thirty patients recovered at least 60° of abduction and rotation (73%). Distal reconstruction was performed in thirty-seven patients, providing finger full extension in all cases but two (95%). CONCLUSIONS: A standardized strategy may be used in extensive proximal BPI, providing overall satisfactory outcomes.

Transfer of the triceps brachii to the finger and thumb extensors: Anatomical study and report on one case.

Our aims were to study the anatomical feasibility of triceps brachii long head (TBLH) transfer to the extensor digitorum communis (EDC) and extensor pollicis longus (EPL) tendons through a medial route, and to report on its first clinical application. Dissections were conducted on 10 fresh-frozen cadaver specimens. Using a posteromedial approach, the TBLH was separated from the remaining triceps and extended distally with a fascia lata strip. This strip was then tunneled through a medial route and secured distally to the EDC and EPL tendons. The transfer tenodesis effect during elbow extension was assessed with metacarpophalangeal (MCP) joint motion of the thumb and index finger, and the distance between the thumb and index finger tips (TI distance). This transfer was performed in an eight-year-old boy with incomplete recovery of a right brachial plexus birth palsy; preoperatively, shoulder and elbow functions were recovered as well as active gripping distally, but he had no active wrist or finger extension. With the trapeziometacarpal and radiocarpal joints stabilized, 90° elbow extension provided a mean extension of the thumb and index finger MCP joints of 34 ± 5° and 90 ± 11°, respectively, with a mean TI distance of 116 ± 16 mm. Twelve months after surgery, the boy had full active MCP joint extension, independent from elbow extension. Transferring the TBLH to the EDC and EPL tendons is anatomically feasible. Larger clinical studies will be needed to assess more adequately its functional outcomes.

Surgical treatment of brachial plexus posterior cord lesion: a combination of nerve and tendon transfers, about nine patients.

Lesions of the posterior cord of the brachial plexus are rare. The symptoms are usually described as palsy of the deltoid and triceps brachii muscles and of the extensor muscles of the wrist, thumb and fingers. If there is no recovery, our strategy is to operate on these patients 6 months after the injury using a combination of nerve and tendon transfers. We present a series of nine patients, two with a partial palsy and seven with a complete palsy of the posterior cord. We performed five nerve transfers to the axillary nerve, four using intercostal nerves and one using the ulnar nerve. Six patients benefited from a transfer to one of the nerves to the triceps brachii (medial or lateral head), five using the ulnar nerve and one using two intercostal nerves. We performed eight tendon transfers for radial palsy. The results demonstrated significant restoration of the deltoid muscle (grade 4 strength, mean active abduction of 120°). Active elbow extension was restored in all patients with an average strength measured at 5.6kg and 48% of the contralateral strength. All tendon transfers were successful with recovery of active wrist extension (40°), long fingers extension and thumb abduction and extension (12.5cm between the tips of index and thumb). With this method, we were able to restore function to the upper limb of patients who presented with debilitating palsy of the posterior cord of the brachial plexus.

The psychoflexed hand: new perspectives in diagnosis, classification and treatment.

The psychoflexed hand is a rare clinical condition characterized by fixed finger contractures undetermined by organic etiology, often associated with a psychiatric pathology. We report a series of 20 patients (nine males and 11 females, mean aged 56.2 years). We have introduced a new classification of the various possible patterns of finger deformities: 1) Type 1: prevalent flexion contracture at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the last two or three fingers; the thumb and the index are not affected; 2) type 2: prevalent flexion contracture at the PIP and distal interphalangeal (DIP) joints of the last two or three fingers; 3) type 3: flexion contracture of all the long fingers; 4) type 4: flexion contracture of all the fingers of the hand, including the thumb (clenched fist syndrome); 5) type 5: isolated flexus-adductus thumb (the long fingers are not affected); 6) type 6: flexion of digits associated with flexion contractures of other joints of the upper extremity. The treatment was conservative in 14 patients with recent deformities and surgical in six patients. Both forms of treatment were followed by a rigorous rehabilitation program, mostly based on home self-rehabilitation. The correction of the deformities was obtained in all cases and maintained over time.

Results of 24 nerve repairs at more than one year post-injury.

There is no consensus in the literature as to the maximum delay for nerve repair following nerve injury. Our aim is to estimate the maximum delay at which a nerve can be successfully reconstructed. Eighteen patients (24 procedures) were operated at more than 12 months (12 to 36) post-injury. Mean age was 38 (17 to 74). There were 18 nerve transfers, four grafts and two secondary sutures for six target muscles. Evaluation of muscle power was scored and assessed against weights starting 12 months follow-up. Finally, two patients had contraction against 7 kg, two against 5 kg, six M4. Two were scored M3 and six were M2, thus 12 good results (67%). This study showed that excellent results could be obtained for nerve repair even after 24 months delay. Further study may be needed to determine the cut-off point of delay after which nerve recovery is unlikely.

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases.

PURPOSE: The aim of this study is to analyse the results of a series of pedicled latissimus dorsi transfers to restore elbow flexion. Moreover, we describe a new technique of distal fixation of the muscle to the proximal third of the ulnar diaphysis to increase the lever arm and improve strength. METHODS: We retrospectively reviewed seven patients aged from 18 to 49 years. Elbow flexion paralysis was secondary to destruction of the anterior arm compartment in four cases and to brachial plexus palsy in three cases. The humeral insertion of the latissimus dorsi was relocated on the coracoid process in five cases and not relocated in two cases. The patients were assessed using the Medical Research Council grading system, the maximum weight lifted by the wrist and the active elbow range of motion. RESULTS: At the last follow-up (mean 26.6 months), five patients recovered M4 elbow flexion strength (0.5 to 8kg), one patient recovered M3 strength and the last transfer failed because of triceps brachii co-contractions. The mean active elbow flexion was 91° (range, 45 to 130°). Patients with destruction of the anterior arm compartment and particularly whose forearm was not paralyzed had better strength than patients with a brachial plexus palsy (3.25 versus 1kg). A skin island with the latissimus dorsi muscle flap was particularly useful in case of arm soft tissue defect. DISCUSSION: A destroyed anterior compartment of the arm is a good indication for latissimus dorsi transfer to restore elbow flexion. The muscle is usually too weak in high brachial plexus palsy. Finally, the latissimus dorsi needs an objective, reproducible and reliable preoperative evaluation. LEVEL OF EVIDENCE: Level IV.

Transfer of the recovered biceps to the long flexors of the digits to restore grip function following complete traumatic brachial plexus palsy.

Restoration of grip function was achieved through transfer of the recovered biceps tendon to the long digital flexors using a fascia lata graft in seven patients with complete brachial plexus palsy. Initial nerve repair was followed by biceps transfer with stabilising wrist and hand fusions. The biceps recovered to Medical Research Council (MRC) grade 4 in all cases. Patients were reviewed at a mean time of 26.7 (range 7-63) months after biceps transfer. After transfer, the total active movement of the digits averaged 55 (range 30-90)8. The strongest measurable grip strength was 6 kg. Patient satisfaction was high. The excellent excursion of the elbow provides a good basis for a transfer to power grip function, enabling a greater total active movement of the fingers to be achieved. We recommend this method as a useful adjunct to the treatment of the complete brachial plexus palsy.

[Management of neuropathic pain after brachial plexus injury in adult patients: a report of 60 cases]. / Prise en charge des douleurs neuropathiques des lésions traumatiques du plexus brachial chez l'adulte. A propos de 60 cas.

An observational study including 60 patients with brachial plexus injury was carried out in order to evaluate the rate of chronic pain, to assess the incidence of neuropathies using the questionnaire DN4 and to record the management of pain in these patients. Chronic pain of neuropathic type according to the questionnaire DN4 was found in 95% of the patients. Although 75% of these cases were treated, only 37% of the patients were satisfied. All of these 37% who were relieved of intense pain (EVA<4) or hyperalgic crisis had an appropriate treatment in the early stages. The proportion of cases considered refractory to an appropriate treatment was lower than 2%. An effort to inform the patients and the carers must be made to improve the management of these injuries. The fact that this pathology is rare must lead to a specialized opinion in order to improve pain management.

[Merkel cell carcinoma of the skin: two case reports located at the hand, with a review of litterature]. / Le carcinome cutané de Merkel: revue de la littérature à propos de deux localisations à la main.

The Merkel cell carcinoma of the skin are rare neuroendocrine tumours, with a dermal location. Their severity and metastatic potential are higher than cutaneous melanomas'. Two cases are reported at the hand. A review of literature displays the pejorative prognosis of these tumours. Hand surgeons must be aware of them, in order to fasten the diagnosis and include the patient among a multidisciplinary medical team.

Ligamentoplasty of the forearm interosseous membrane using the semitendinosus tendon: anatomical study and surgical procedure.

Total longitudinal disruptions of the interosseous membrane can allow proximal radius migration and are seen in Essex-Lopresti lesions. We propose an original technique of ligamentoplasty using the semitendinosus tendon. The graft corresponds to the forearm rotation axis for an optimized isometry and longitudinal stabilization. Our ligamentoplasty technique was performed on ten fresh frozen right forearms. We successively assessed the innocuousness, efficiency and resistance of the ligamentoplasty. The ligamentoplasty induced neither passive limitation of pronation-supination nor neurovascular lesions. It prevented from radius proximal migration. The mean load to failure was 28 kg at both ulnar and radial sides of the graft. Our technique is original for the type and position of the graft. It seems safe, efficient and resistant enough for in vivo procedures. This technique decreases longitudinal loads on the radius. It should be indicated in patients with Essex-Lopresti syndrome, in association with radial head internal fixation or arthroplasty.

[Ralstonia pickettii osteomyelitis of the trapezium]. / Osteite du trapèze a Ralstonia pickettii: a propos d'un cas et revue de la littérature.

An immunocompromised 29-year-old man presented with a Ralstonia pickettii osteomyelitis affecting the trapezium bone. The patient underwent two surgical debridement stages, including trapezectomy and long-term drainage. The type of the contaminant organism and the trapezium localization make this observation atypical.