Redefining the Inclusion Criteria for Successful Steindler Flexorplasty Based on the Outcomes of a Case Series in Eight Patients.

Background (rationale) Steindler flexorplasty (SF) is aimed at restoring independent elbow flexion in the late stages of dysfunction of the primary elbow flexors. Selection criteria for successful SF have been defined. Objectives The purpose of this study was to redefine the inclusion criteria for successful SF based on functional outcomes. Methods Eight patients received SF after an average of 50.8 months after injury or dysfunction. Three patients (37.5%) met all five Al-Qattan inclusion criteria (AQIC), and another five patients (62.5%) met four or less AQIC. Patients were followed up for at least 9 months, and the maximum range of active elbow flexion (REF) was measured. Functional results of SF were assessed using the Al-Qattan scale (in accordance with Al-Qattan's scale). Results The mean maximum REF was 100 degrees (70 to 140 degrees). Five patients reached REF greater than 100 degrees. One patient had a poor outcome, two patients (25%) had a fair outcome, three patients (37.5%) had a good outcome, and two patients (25%) had an excellent outcome of SF on the Al-Qattan scale. The impact of each AQIC on functional outcome has been critically reviewed from a biomechanical point of view. Conclusions The sufficient number of inclusion criteria required for successful SF can be reduced from five (according to AQIC) to two; Normal or near-normal function (M4 or greater on the MRC scale) of the muscles of the flexor-pronator mass should be considered an obligatory inclusion criterion, while primary wrist extensors may be considered an optional inclusion criterion.

Nerve transfers in a patient with asymmetrical neurological deficit following traumatic cervical spinal cord injury: simultaneous bilateral restoration of pinch grip and elbow extension. Illustrative case.

BACKGROUND: Cervical spinal cord injury (CSCI) causes severe motor deficit in upper extremities. The mixed segmental CSCI pattern is reflected in the combination of time-sensitive (TS) and non-TS myotomes in the upper extremities. Nerve transfers (NTs) restore upper extremity function yet remain TS procedures. A combination of neurological, magnetic resonance imaging (MRI), and electromyography (EMG) studies allows the identification of TS and non-TS myotomes in the upper extremities. OBSERVATIONS: Nineteen months after NTs, flexor pollicis longus (FPL) and deep flexor of the index finger (FDP2) recovered to M4 (right UE), FPL recovered to M3 and FDP2 to M2 (left EU). The long head of the triceps brachii muscle recovered to M4 bilaterally. The Capabilities of Upper Extremity Questionnaire (CUE-Q) score for unilateral arm functionality increased by 44% (right) and 112.5% (left) and for bilateral arm functionality by 400%; the CUE-Q score for unilateral hand and finger function increased by 283% (right) and 166% (left). LESSONS: The combination of neurological, MRI, and EMG studies before surgery and data obtained during surgery provides reliable information on the CSCI pattern, specifically the availability of motor donor nerves. Simultaneous bilateral restoration is required in the event of CSCI and significantly improves the unilateral and bilateral function of the UEs.

Transfer of the anterior C3 levator scapulae motor nerve branch for spinal accessory nerve injury: illustrative case.

BACKGROUND: Injury to the spinal accessory nerve (Acc) results in loss of motor function of the trapezius muscle and leads to severe shoulder problems. A vast number of surgical strategies have been proposed to reinnervate (suture, grafting, and nerve transfers) or compensate (tendon and muscle transfers) the lost function of the trapezius muscle. OBSERVATIONS: The authors report a successful case of Acc reconstruction 5 months after the injury with the anterior C3 levator scapulae motor nerve branch transfer in omotrapezoid triangle of the neck. LESSONS: The advantages of the proposed technique over preexisting nerve transfers were discussed. We believe that this technique can be considered as an alternative to already existing techniques for proximal injuries to Acc.

SURGICAL TREATMENT OF PERIPHERAL NERVES COMBAT WOUNDS OF THE EXTREMITIES.

OBJECTIVE: The aim: Improving the effectiveness of patients' treatment with combat injuries of the peripheral nervous system, which consists in the application and development of new methods of reconstructive interventions, optimizing a set of therapeutic and diagnostic measures for the most effective management of this category of patients with peripheral nerve injury. PATIENTS AND METHODS: Materials and methods: The research is based on the results of surgical treatment of 138 patients with combat injuries of peripheral nerves for the period from 2014 to 2020. The mean age was 33.5 ± 2.1 years. Patients were treated for 1 to 11 months after injury (median - 8 months). Damage to the sciatic nerve was observed in 26.1%, ulnar - in 20.3%, median - in 18.8%, radial - in 15.9%, tibial - in 10.9%, common peroneal nerve - in 8% of cases. RESULTS: Results: It was shown that in all patients was significantly improved the recovery of all nerves. In the period from 9 to 12 months, the degree of recovery of motor function to M0-M2 was observed in 40.6%, to M3 - in 35.5%, to M4 - in 16.7%, to M5 - in 7,2%. The degree of recovery of sensitivity to S0-S2 was observed in 36.2%, to S3 - in 42.8%, to S4 - in 17.4%, to S5 - in 3.6%. Regression of pain syndrome after surgery was observed in 81.2% of patients. CONCLUSION: Conclusions: The results of surgical treatment of peripheral nerves gunshot injury are generally worse than other types of nerve injuries. The best results of surgical treatment of combat trauma of peripheral nerves are obtained in patients with sciatic nerve damage.

Choosing the target wisely: partial tibial nerve transfer to extensor digitorum motor branches with simultaneous posterior tibial tendon transfer. Could this be a way to improve functional outcome and gait biomechanics?

OBJECTIVE: The objective of this study was clinical assessment of the reduction of pathological motor phenomena with the recovery of long toe extensors, and evaluation of functional outcome with simultaneous nerve and tendon transfer in cases of common peroneal nerve (CPN) injuries. METHODS: Seven male patients (mean age 26.4 years) received a partial tibial nerve transfer to the extensor hallucis longus muscle (MEHL) and extensor digitorum longus muscle (MEDL) motor branches, after a mean of 2.7 months following a traction-type injury to the CPN. Tibialis posterior muscle (MTP) tendon transfer through the interosseous route was performed on the same day. The follow-up period included a clinical neurological examination, a modified Stanmore System questionnaire (MSSQ), electromyographic examination of the interference pattern, and a video-based analysis of the gait biomechanics in the 3rd and 12th months. Video analysis of the gait investigated the presence or reduction of "stair-climbing maneuver" (SCM), foot slap (FS), and foot stability during the gait cycle. RESULTS: The average range of active dorsiflexion in the 3rd month was 0.85°. SCM accompanied walking in 6 patients (86%). FS accompanied walking in 3 patients (43%) and 3 patients (43%) avoided FS by planting the entire foot on the ground. All patients required orthopedic support (shoe inserts) to compensate for mediolateral foot instability. The average MSSQ score was 80.4 points. The average duration for the effective recovery of function (≥ 4 points on the Medical Research Council grading system) of long toe extensors was 11.2 months. The average range of active dorsiflexion in the 12th month increased to 4.4°. A reduction of FS was observed in 5 patients (71%). Excessive foot eversion was reduced in 4 patients (57%). Another 3 patients (43%) required no specific orthopedic shoe inserts. Reduction of pathological motor phenomena with recovery of the long toe extensors resulted in an increase of functional outcome. The average MSSQ score after 12 months was 92.4 points. CONCLUSIONS: Partial tibial nerve transfer to the motor branches of the extensor hallucis longus and the long toe extensors along with the simultaneous tibialis posterior tendon transfer produce the reduction of FS and bring mediolateral stability to the foot, i.e., improved gait biomechanics. The reduction of pathological motor phenomena at the time of recovery of the long toe extensors is reflected in an increase in patients' functional perception of the injured lower extremity during daily walking.

Denervation and myotomy of muscles of the omotrapezoid triangle of the neck improve the outcomes of surgical treatment of laterocollis and torticollis subtypes of spasmodic torticollis: 58 case analysis.

BACKGROUND: The main objective of this study was to analyze the outcomes of denervation and myotomy of the muscles of the omotrapezoid triangle of the neck in the treatment of 58 patients with the laterocollis and torticollis subtypes of spasmodic torticollis. METHODS: Fifty-eight patients with the laterocollis and torticollis subtypes of spasmodic torticollis underwent 135 staged microsurgical denervations, including 25 denervation and myotomy procedures on the dystonic muscles of the omotrapezoid triangle (Tretyak's procedure). The outcome evaluation was conducted via neurological examination and the Toronto Western Spasmodic Torticollis Rating Scale (Severity subscale). RESULTS: Tretyak's procedure allowed us to improve the outcomes of surgical treatment of the latero- and torticollis subtypes of spasmodic torticollis. Ninety-two percent of patients who underwent the denervation of the muscles of the omotrapezoid triangle moved to the group with lower ST severity-predominantly to the group with mild severity (21 patients out of 25). Tretyak's procedure appeared to be effective in 100 % of patients with the torticollis subtype of ST (15 patients out of 15) and in 80 % of patients with the laterocollis subtype of ST (8 patients out of 10). CONCLUSIONS: Tretyak's procedure appears to be an excellent additional surgical procedure in terms of improvement of the outcomes of the "classic" Bertrand microsurgical denervation of the muscles of the neck in patients with the latero- and torticollis subtypes of spasmodic torticollis; staging of surgical denervation of muscles of the neck in the treatment of patients with the latero- and torticollis subtypes of spasmodic torticollis allows the surgeon to precisely evaluate the outcomes of previously conducted procedures, individualize the surgical approach by providing the necessary time and space to create a well-defined plan and thoroughly define the aims of further surgical denervation.

Biocompatible heterogeneous porous gel matrix NeuroGel(TM) promotes regeneration of rat sciatic nerve within tubular silicone prosthesis (experimental study).

BACKGROUND: The purpose of this study was to investigate the ability of NeuroGel™ to promote and enhance the regeneration of rat sciatic nerve within a 10-mm gap using silicone tubular prosthesis, and to evaluate and compare the regeneration outcomes versus autologous grafting. METHODS: The 10-mm gap of rat sciatic nerve was bridged through silicone tubular prosthesis filled with dehydrated NeuroGel™, and NeuroGel™ saturated with rat NGF-B (NG30-NGG60, NGgfB30-NGgfB60). To assess the regeneration of the peripheral nerve we utilized three general and most commonly applied methods: electrophysiologic, hystomorphometric, and functional methods. RESULTS: The average M-wave amplitude (AMW index), or the intermediary index of the number of regenerated axons, in animal groups NGG60 and NGgfB60 60 days post-op was: 2.44 ± 0.57 mV and 1.87 ± 0.48 mV. These indices were statistically lower compared to the indices obtained after autologous grafting. The average impulse conduction velocity along motor fibers (VMF index), or the intermediary index of myelination rate, was: 13.3 mm/ms and 13.3 mm/ms, respectively, statistically equal to indices obtained after autologous grafting. The average density (D) of regenerated fibers (direct numerical indicator in contrast to intermediary AMW index) in animal groups NGG60 and NGgfB60 was: 4,920 ± 178.88 and 5,340 ± 150.33 per mm(2), respectively. These indices were statistically higher versus indices obtained after autologous grafting. Myelination rates of regenerated fibers in animal groups NGG60 and NGgfB60 were 73 and 86 %, respectively. They were also statistically higher. The average sciatic functional index (SFI) in NGG60 and NGgfB60 was: -25.57 ± 3.05 and -24.124 ± 4.8, respectively, which is statistically equal to indices obtained after autologous grafting. CONCLUSIONS: Neurogel™ strongly promotes the regeneration of rat sciatic nerve within silicone tubular prosthesis. After bridging a 10-mm gap through silicone prosthesis with Neurogel™ or Neurogel™ +NGF-B-modified intraluminal space, the myelination rate of regenerated axons of rat sciatic nerve appeared to be higher, and the axon count and functional recovery is similar to results seen with the autografting technique.