Distal nerve transfers for peripheral nerve injuries: indications and outcomes.

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

[HIP FRACTURE SURGERY DELAY IN PATIENTS TREATED WITH ORAL ANTICOAGULANTS: RESULTS FROM SHEBA MEDICAL CENTER].

BACKGROUND: Hip fractures (HF) are a major cause of morbidity and mortality in the elderly population. Many factors are associated with HF post-operative prognosis, among them the admission to operation time (AOT) is a major factor. Delayed surgery (> 48 hours) is associated with increased morbidity and mortality. The use of anti-coagulants (OAC) often leads to surgery delay to prevent possible surgical bleeding. OBJECTIVES: To test the association between the use of OAC and AOT. METHODS: The study was a retrospective cohort of consecutive patients above 65 years of age admitted and operated for hip fracture at the Sheba Medical Center between the years 2014-2018. We compared AOT between OAC treated and non-treated patients. We conducted multi-variable analysis to examine the effect of OAC on AOT. RESULTS: Overall, 1013 case patients were studied, among them 151 were treated with OAC (research group) and 865 patients without any anti-coagulation treatment (control group). Surgery delay over 48 hours was observed in 24.6% OAC treated patients compared to 12% in the non-treatment group (p=0.0001). Median AOT was 32 hours compared to 24.6 hours in treated vs non-treated patients, respectively, p=0.0001. Apixaban is the only drug found not to prolong AOT. In multivariate analysis OAC therapy was the only significant cause for surgical delay. CONCLUSIONS: Patients with HF treated with anti-coagulants are experiencing delayed surgery compared to non-treated patients.

Transdeltoid Approach to Axillary Nerve Repair: Anatomical Study and Case Series.

PURPOSE: In cases of isolated paralysis of the axillary nerve, dissection of the distal stump at the posterior deltoid border can be difficult because of scarring from an injury or previous surgery. To overcome this, we propose dissecting the anterior division of the axillary nerve (ADAN) using a deltoid-splitting approach. We investigated the anatomy of the ADAN as it pertains to the transdeltoid approach and report the clinical application of this approach in 9 patients with isolated axillary nerve injury. METHODS: The axillary nerve and its branches were dissected in 9 fresh cadaver specimens. In the clinical series, 1 patient with a lesion confined to the ADAN underwent nerve grafting. In the remaining 8 patients, the ADAN was repaired by transferring the triceps lower medial head and anconeus (TLMA) motor branch via a single-incision or double-incision posterior arm approach. RESULTS: The posterior division of the axillary nerve does not travel around the humerus. It innervated the posterior deltoid and teres minor muscles. At the posterior margin of the humerus, the ADAN ran adjacent to the teres minor tendon. The ADAN's trajectory on the lateral side of the humerus was 65 mm (SD ± 8 mm) from the midpoint of the acromion. One centimeter from the origin, the ADAN offered a prominent branch to the middle deltoid and wound around the humerus anteriorly at the surgical neck just distal to the infraspinatus tendon. A transdeltoid approach was feasible in all our patients. The TLMA was reached without any tension in the ADAN. Middle deltoid strength in 1 patient who had received a graft scored M3, while anterior and middle deltoid strength in the remaining patients who underwent nerve transfers scored M4. CONCLUSIONS: With axillary nerve lesions, reinnervation of the ADAN is a priority. The transdeltoid approach between the posterior and middle deltoid offers a direct and feasible approach to the ADAN. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Bilateral Ulnar Nerve Injury in the Wrist: Comparison of First Webspace Muscle Reconstruction by Opponens Nerve Transfer in the Right Hand Versus Direct Ulnar Nerve Repair in the Left Hand.

We report a case of a bilateral glass injury to the wrist with transection of flexor tendons and the ulnar nerve and artery in a 60-year-old male patient. Two days after his accident, we repaired all divided structures, and on the right hand, we added the transfer of the opponens motor branch to the deep terminal division of the ulnar nerve aimed at first dorsal interosseous and adductor pollicis muscle reinnervation. After surgery, the patient was followed over 24 months. Postoperative dynamometry of the hand, which included grasping, key-pinch, subterminal-key-pinch, pinch-to-zoom, and first dorsal interosseous muscle strength, indicated recovery only in the nerve transfer side.

The Cutaneous Branches of the Median and Ulnar Nerves in the Palm.

PURPOSE: The dermatomal distributions of the ulnar and median nerves on the palmar skin of the hand have been studied thoroughly. However, the anatomic course of the median and ulnar cutaneous nerve branches and how they supply the skin of the palm is not well understood. METHODS: The cutaneous branches of the median and ulnar nerves were dissected bilaterally in 9 fresh cadavers injected arterially with green latex. RESULTS: We observed 3 groups of cutaneous nerve branches in the palm of the hand: a proximal row group consisting of long branches that originated proximal to the superficial palmar arch and reached the distal palm, first web space, or hypothenar region; a distal row group consisting of branches originating between the superficial palmar arch and the transverse fibers of the palmar aponeurosis (these nerves had a longitudinal trajectory and were shorter than the branches originating proximal to the palmar arch); and a metacarpophalangeal group, composed of short perpendicular branches originating on the palmar surface of the proper palmar digital nerves at the web space. The radial and ulnar borders of the hand distal to the palmar arch were innervated by short transverse branches arising from the proper digital nerves of the index and little finger. Nerve branches did not perforate the palmar aponeurosis in 16 of 18 cases. CONCLUSIONS: The palm of the hand was consistently innervated by 20-35 mm long cutaneous branches originating proximal to the palmar arch and shorter branches originating distal to the palmar arch. These distal branches were either perpendicular or parallel to the proper palmar digital nerves. CLINICAL RELEVANCE: Transfer of long proximal row branches may present an opportunity to restore sensibility in nerve injuries.

Two clinical tests assessing long thoracic nerve function to determine C5 and C6 root graft eligibility in patients with brachial plexus injury.

OBJECTIVE: Identifying roots available for grafting is of paramount importance prior to reconstructing complex injuries involving the brachial plexus. This is traditionally achieved by combining input from both clinical examinations and imaging studies. In this paper, the authors describe and evaluate two new clinical tests to study long thoracic nerve function and, consequently, to predict the status of the C5 and C6 roots after global brachial plexus injuries. METHODS: From March 2020 to December 2020, in 41 patients undergoing brachial plexus repair, preoperative clinical assessments were performed using modified C5 and C6 protraction tests, C5 and C6 Tinel's signs, and MRI findings to predict whether graft-eligible C5 and C6 roots would be identified intraoperatively. Findings from these three assessments were then combined in a logistic regression model to predict graft eligibility, with overall predictive accuracies calculated as areas under receiver operating characteristic curves. RESULTS: In the 41 patients, the pretest probability of C5 root availability for grafting was 85% but increased to 92% with a positive C5 protraction test and to 100% when that finding was combined with a positive C5 Tinel's sign and favorable MRI findings. The pretest probability of C6 root availability was 40%, which increased to 84% after a positive C6 protraction test and to 93% when the protraction test result concurred with Tinel's test and MRI findings. CONCLUSIONS: Combining observations of the protraction tests with Tinel's sign and MRI findings accurately predicts C5 and C6 root graft eligibility.

The Effect of Malunited Scaphoid Fractures on Joint Congruency.

PURPOSE: Although the consequences of scaphoid nonunion have been well-established, the implications of malunions are not well-known. To date, malunions have mainly been studied with 2-dimensional imaging. The objective of this study was to employ 3-dimensional computed tomography (CT) imaging and inter-bone distance mapping to determine the implications of a scaphoid malunion on 3-dimensional joint surface area (JSA) (a measure of joint contact area) at an average of 7 ± 2 years (range, 4-12 years) after fracture. METHODS: In 14 subjects with previous unilateral, malunited scaphoid fractures, we measured the 3-dimensional JSA using reconstructed CT bone models of the carpus. The JSA was compared within each individual, comparing images of the wrist collected at the time of fracture (baseline) and 7 years later (follow-up CT scans). RESULTS: There was a significant increase in the measured JSA (reduced joint space) at the scaphotrapezial (23% increase) and scaphocapitate (13% increase) joints when the baseline and follow-up scans of the wrist were compared. An increased JSA indicates that the 2 opposing surfaces are closer in contact and have a reduced joint spacing reflective of degenerative changes. However, participants in this study showed no radiographic signs of degenerative changes in the wrists at midterm follow-up. CONCLUSIONS: An increase in JSA was found in patients with a malunited scaphoid in the scaphotrapezial and scaphocapitate joints of the wrist an average of 7 years after injury, but these joint changes were not evident in measured radiographic signs of arthritis. CLINICAL RELEVANCE: As early as 4 years after injury, the 3-dimensional JSA is significantly increased at the scaphocapitate and scaphotrapezial joints. Future work is needed to determine the implication of this increased in 3-dimensional JSA on the underlying subchondral bone, and to observe these patients for longer to determine whether degenerative changes develop.

Static and Dynamic External Fixation are Equally Effective for Unstable Elbow Fracture-Dislocations.

OBJECTIVE: To compare the clinical outcomes of static versus dynamic external fixation for elbow fracture-dislocations with persistent instability after surgical management. DESIGN: Comparative, retrospective review. SETTING: Two tertiary referral upper-extremity centers. PATIENTS: Twenty-four elbows requiring external fixation for persistent elbow instability within 90 days of surgical management of an elbow fracture-dislocation. INTERVENTION: Static and dynamic external fixation was used in 16 and 8 patients, respectively, for a median of 39 days (interquartile range, 33-48 days). MAIN OUTCOME MEASUREMENTS: Elbow range of motion, complications, and revision surgeries. RESULTS: Immediately after static and dynamic external fixation removal, there was no difference in elbow extension [33 degrees ± 16 degrees vs. 41 degrees ± 13 degrees, mean difference (MD) 7 degrees, 95% confidence interval (CI) -6 degrees-22 degrees] or flexion (114 degrees ± 35 degrees vs. 118 degrees ± 11 degrees, MD 4 degrees, 95% CI -23 degrees-132 degrees), respectively. At last follow-up, static and dynamic external fixation groups had no difference in elbow extension (27 degrees ± 13 degrees vs. 24 degrees ± 10 degrees, MD -3 degrees, 95% CI -15 degrees-7 degrees) or flexion (129 degrees ± 12 degrees vs. 128 degrees ± 14 degrees, MD -1 degree, 95% CI -13 degrees-10 degrees), respectively. Static and dynamic external fixation groups had no difference in complications [7 (44%) vs. 5 (63%), difference 19%, 95% CI -23%-54%] or revision surgeries [6 (38%) vs. 4 (50%), difference 13%, 95% CI -27%-49%]. CONCLUSIONS: No difference in range of motion, complications, and revision surgeries was detected after static versus dynamic external fixation of persistently unstable elbow fracture-dislocations. Due to ease of application, static external fixation is our preferred treatment for these injuries. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Scaphoid Malunion Clinical and Radiographic Outcomes at a Minimum of 4 Years Follow-Up.

PURPOSE: To evaluate the radiographic and clinical outcomes of patients with scaphoid malunion after acute fracture at a mean of 7 years after injury. METHODS: Patients with scaphoid malunion were identified from a departmental database of acute scaphoid fractures. Patients with a scaphoid height-to-length ratio greater than 0.6 on final follow-up computed tomography (CT) scan were considered malunited. These patients were contacted to return for CT imaging and clinical assessment. A total of 22 patients were included (4 females and 18 males). Average age of the group was 41 years (range, 16-64 years) and average length of follow-up was 7.4 years (range, 4.4-11.8 years) after injury. RESULTS: Ten patients who underwent CT imaging demonstrated arthritic changes at the radial styloid, scaphoid fossa, or scaphotrapeziotrapezoid joint(s). Despite this, patients had good clinical function that was not significantly different compared with the uninjured side. Patients reported minimal pain and disability based on patient-reported outcome measures, and there was a moderate correlation between passive range of motion and height-to-length ratio. CONCLUSIONS: Nearly half of all patients with malunited acute scaphoid fractures demonstrated radiographic findings of early arthritis on CT imaging but overall good clinical results on midterm follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

The Natural History of Scaphoid Fracture Malunion: A Scoping Review.

Background A scaphoid malunion occurs when a scaphoid fracture heals in a nonanatomic position or when the fracture is fixed without correction of the sagittal angular deformity. Although altered carpal mechanics and early osteoarthritis have been suggested as natural sequelae, the natural history and clinical outcomes are debatable. Purposes The purpose of this study is to review and summarize the available literature regarding clinical, functional, and radiographic outcomes of patients with scaphoid malunion. Methods A systematic search of the MEDLINE/PubMed, EMBASE, Cochrane Library, and Web of Science was performed to identify published studies concerning the clinical and radiological results of scaphoid malunion following either acute scaphoid fracture or surgically treated nonunions. Results Five publications with a total of 83 malunions were included in the final synthesis. The diagnosis of malunion was based on computed tomography by calculating the lateral intrascaphoid angle (threshold of 35 or 45 degrees) or height/length ratio (threshold of 0.6). Self-reported and clinical evaluation techniques varied between the studies and direct comparison was not possible between the different outcome measures. Most patients demonstrated arthritic changes; however, correlation with pain and functional results was not always present. Conclusions This scoping review confirmed that patients with malunited scaphoids seem to have higher likelihood of post traumatic arthritis. However, clinical implications remain uncertain and better methods for assessing and defining scaphoid deformity are required.

Is a radiograph needed one week after internal fixation of a supracondylar humeral fracture?

Displaced supracondylar fractures of the humerus (SCFH) require surgical treatment, most commonly closed reduction with pin fixation. Postoperative displacement following pin fixation is uncommon. Routinely, an early follow-up visit with a radiograph was recommended after fixation of SCFH. The aim of this study was to examine the rate of displacement of SCHF treated with pin fixation using objective radiologic measurements and to determine the need for the early follow-up radiographs. We retrospectively reviewed 161 patients with displaced SFCH treated surgically. The primary outcome measure was loss of reduction (LOR). We examined patient and fracture characteristics and postoperative complications. LOR was defined as a change of 5° or more in measurement of Bauman's angle or the lateral capitellohumeral angle. After applying exclusion criteria, the study group consisted of 131 patients; 87 (66.4%) were male; the left limb was involved in 76 patients (58%); 98 were classified as Gartland type 3 (74.8%); 118 patients had extension type fractures (90%); complications included nerve injury in 32 patients (24.4%), mostly involving the ulnar nerve (17, 13%). Pin-tract infection occurred in four patients (3%). LOR was found in five patients (3.8%). In all these patients, there was evidence of inadequate fixation in the intraoperative radiographs. When adequate fixation is obtained intraoperatively, the next follow-up radiograph is recommended after 3 weeks, at the time of pin removal.

Management of chronic distal biceps tendon ruptures: primary repair vs. semitendinosus autograft reconstruction.

BACKGROUND: Delayed presentation of distal biceps tendon ruptures can make primary repair difficult, in which case reconstruction using a tendon graft is an option. The aim of this study was to compare outcomes and complications between delayed distal biceps tendon ruptures managed with repair vs. semitendinosus autograft reconstruction. METHODS: Nineteen delayed distal biceps tendon rupture cases treated with a tendon reconstruction were compared with 16 delayed primary repair cases (>21 days). The reconstructions were performed using a semitendinosus autograft looped through a transosseous tunnel in the bicipital tuberosity and secured with a Pulvertaft weave to the remnant distal biceps tendon. The patient groups were reviewed and completed functional outcomes testing including range of motion, isometric elbow flexion and supination strength, Disabilities of the Arm, Shoulder, and Hand, Patient-Rated Elbow Evaluation, Single Assessment Numeric Evaluation, and Mayo Elbow Performance Index. RESULTS: Mean patient age (49 ± 9 vs. 46 ± 8 years, P = .65) and follow-up (47 ± 25 vs. 45 ± 27 months, P = .45) were similar between delayed primary repair and reconstruction groups. Range of motion (P = .62), supination strength (P = .26), elbow flexion strength (P = .93), Disabilities of the Arm, Shoulder, and Hand (P = .08), and Single Assessment Numeric Evaluation (P = .22) were not significantly different between groups. The Patient-Rated Elbow Evaluation (P = .02) and Mayo Elbow Performance Index (P = .04), however, were better in the delayed repair group compared with the reconstruction group. Complications were similar between groups (P = .87). CONCLUSION: Delayed reconstruction of irreparable distal biceps tendon ruptures with semitendinosus autograft produces similar strength, range of motion, and complication rates but slightly worse functional outcome scores compared with delayed primary repair. This suggests that when possible direct repair is preferred, however, if not possible, reconstruction with an autologous tendon graft results in predictably good outcomes.