Anatomically based radiological classification of thumb basal joint arthritis.

The numerous surgical techniques proposed for treating thumb basal joint arthritis (osteotomy of the first metacarpal, trapezial osteotomy, simple trapeziectomy, trapeziectomy with implant, total joint prosthesis, arthroplasty by interposition, etc.) necessitate an anatomically based radiological evaluation of the different pathological forms of thumb basal joint arthritis. Here, the author defines three parameters: narrowing of the trapeziometacarpal (TM) joint space: TMA; TM instability and subluxation: TM I; scaphotrapeziotrapezoid damage: STT. Four stages of TM osteoarthritic deterioration are defined: TMA0: no joint narrowing (painful and unstable joint); TMA1: narrowing <50%; TMA2: narrowing>50%; TMA3: disappearance of the joint space, bone erosions. For TM instability/subluxation: TMI 0: reducible subluxation (unstable and painful TM); TMI 1: reducible subluxation but with imperfect reintegration; TMI 2: non-reducible subluxation <1/3; TMI 3: subluxation>1/3. For STT damage, STT 0: radiograph is normal but anatomical damage is visible intraoperatively; STT 1: joint space narrowing <50%; STT 2: joint space is barely visible; STT 3: presence of erosion, sclerosis, irregularities. He outlines the shortcomings of the often-used Dell and Eaton-Littler classifications. A prospective study involving multiple cases having the same anatomical and radiological appearance that are assessed with sufficient follow-up is needed to standardize the modalities of surgical treatment.

40 years of experience in functional surgery of the tetraplegic upper limb.

The author relates his 40 years of experience in the field of functional surgery of the tetraplegic upper limb (FSTUL). After having introduced and developed this specialty in France, he disseminated it to various countries where he saw a large number of patients and acquired extensive experience. He presents his personal progression and discusses the recent therapies in this field. FSTUL is a personalize surgery, with each case being unique. It must, first and foremost, take into consideration the real wishes of a motivated and well-informed patient and consider the type of spinal cord injury (not only the upper level of the lesional segment but also the extent of the sub-lesional segment). The surgical indication and rehabilitation are very important factors in the outcome. The main goal of FSTUL is rapid social reintegration of the patient; in some cases, this could involve fewer surgical procedures and shorter stays in rehabilitation centers. FSTUL is in constant evolution and can be improved; it is a useful but not well-known surgery.

[Surgical management of the adult spastic hand]. / Prise en charge de la main spastique de l'adulte.

The adult spastic hand, of varying causes, but dominated by vascular hemiplegia and brain damage, associates motor disorders and problems of tonus. The variety of forms of brain damage explains the wealth and diversity of the symptoms. These symptoms, often the most serious along with cognitive disorders, justify the expression "central neurological hand". Each case is an individual one. The effect on the hands may be unilateral or bilateral with spasticity involving the fingers/thumb/wrist. The clinical evaluation leading to a decision tree must take into account spasticity, retraction and paralysis, for each muscle. When completed by anesthetic motor blocks, spasticity and/or retraction, damage to extrinsic and/or intrinsic muscles of the fingers may be differentiated. This repeated multidisciplinary evaluation makes it possible to distinguish between "non functional hands", "functional hands" and "potentially functional hands". In the first instance, surgery can only improve the esthetic aspect or facilitate nursing. In the second instance, correcting spasticity may improve function. The treatment of spasticity is based on inhibiting spasticity (by injecting botulinum toxin or surgical motor hyponeurotisation) and reinforcing the non-spastic antagonist muscles via tendon transfer or tenodesis. Surgery is indicated to correct muscular retraction and deformities. The functional indications are highly selective and their limited results only allow a "supporting hand" to be constructed at best. The non-functional indications lead to a codified intervention whose results will greatly improve the management of these patients.

[Surgical management of spasticity of the intrinsic muscles of the long fingers in adults after cerebral palsy, 68 operated hands]. / Prise en charge chirurgicale de la spasticité des muscles intrinsèques des doigts longs dans la main spastique de l'adulte cérébrolésé, à propos de 68 mains opérées.

Between November 2001 and January 2008, 56 patients (68 hands) out of 110 patients operated for spastic hand deformities, presented with spasticity of the intrinsic muscles of the long fingers (interosseii and the abductor pollicis brevis). All patients were adults (mean age 42.1 years). The surgical indication was discussed during multidisciplinary consultations with selective nerve blocks enabling us to distinguish between extrinsic and intrinsic pathologies on the one hand and muscular spasticity and tendon retractions on the other hand. The aim of the treatment was defined in a "contract" signed with the patient and/or his family. It was hygienic, aesthetic and analgesic in 15 cases, hygienic and analgesic in 32 cases and functional in 21 cases. Four hands were treated by neurectomy of the ulnar nerve's motor ramus, 54 by tenotomies of the interosseous muscles, 18 by tenotomy of the abductor digiti minimi, six by metacarpal disinsertion of the interosseous muscles. On a total of 67 hands operated associating surgery of the extrinsic and intrinsic flexors, 63 had good primary results as defined in the contract. We noted four relapses, two of which required revision. The authors emphasize the frequency of mixed spastic hands in adults after cerebral palsy. However modest the functional results may be, correction of hygienic and pain problems of non-functional hands as well as aesthetic improvements make surgery of the mixed spastic hand a successful intervention, which should be shared.

[Past, present and future of vascularised bone transfers in the hand and wrist]. / Passé, présent et avenir des transferts osseux vascularisés à la main et au poignet.

The author specifies the aims and indications for simple or compound pedicle or free vascularised bone and bone and joint grafts (VBGs and VBJGs). He relates the history of VBGs whose indications for the wrist are often many and varied for the treatment of scaphoid non-union and Kienböch's disease. Within the hand the indication for compound VBGs is dominated by thumb reconstruction (skin and bone grafts). Compound VBGs and VBJGs used in an emergency for hand trauma, harvested from another irrecoverable long finger (bank finger) are extremely varied and adapted to each particular case. For secondary joint reconstruction in the adult, VBJGs must be discussed along with prosthetic arthroplasties (radio-carpal, lower radio-ulnar, trapezo-metacarpal, interphalangeal). For children VBJGs with an included growth plate maintain their indication. The immediate future of VBGs is that of a better knowledge of bone necrosis and bone innervation as well as an improvement in surgical techniques: microsurgery and robotics, mini-invasive surgery (wrist arthroscopy). The near future for VBGs is to control bone consolidation thanks to progress in the bio-engineering of bone tissue, which may make them obsolete and, for VBJGs, vascularised joint allografts, thanks to progress in immunosuppressant treatments. Although the immediate future and this near future may be envisaged according to the current advances, the same is not true for the distant future which remains totally unforeseeable, although this might involve regeneration and construction of organs by man himself.

Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: technique and results.

We report the results of performing a pronating osteotomy of the radius, coupled with other soft-tissue procedures, as part of an upper limb functional surgery programme in tetraplegic patients with supination contractures. In total 12 patients were reviewed with a mean follow-up period of 60 months (12 to 109). Pre-operatively, passive movement ranged from a mean of 19.2 degrees pronation (-70 degrees to 80 degrees ) to 95.8 degrees supination (80 degrees to 140 degrees ). A pronating osteotomy of the radius was then performed with release of the interosseous membrane. Extension of the elbow was restored postoperatively in 11 patients, with key-pinch reconstruction in nine. At the final follow-up every patient could stabilise their hand in pronation, with a mean active range of movement of 79.6 degrees (60 degrees to 90 degrees ) in pronation and 50.4 degrees (0 degrees to 90 degrees ) in supination. No complications were observed. The mean strength of extension of the elbow was 2.7 (2 to 3) MRC grading. Pronating osteotomy stabilises the hand in pronation while preserving supination, if a complete release of the interosseous membrane is also performed. This technique fits well into surgical programmes for enhancing upper limb function.

[Primary flexor tendon ruptures of the little finger within the carpal tunnel. Proposed classification based on six clinical cases and review of the literature]. / A propos des ruptures primitives du fléchisseur du cinquième doigt au canal carpien. Essais de classification basée sur six cas cliniques et revue de la littérature.

Six cases of primary flexor tendon rupture of the little finger within the carpal tunnel are presented. All of them were attritional ruptures caused by a rough hook of the hamate. These ruptures are rare. They have their place among the flexor tendon ruptures of the wrist and the palm. Ultrasound may by helpful to determine the level of rupture. The surgical treatment consists of excision of the hook of the hamate and tendon repair.

[Scapulohumeral arthrodesis for non-neurological shoulder: a study of 8 cases]. / L'arthrodèse scapulo-humérale dans l'épaule non neurologique: à propos de 8 ans.

PURPOSE OF THE STUDY: Scapulohumeral arthrodesis is mainly used for the treatment of sequelar injury after brachial plexus palsy. Indications are however controversial and limited to patients with non-neurological shoulders. We report a series of eight shoulder arthrodeses performed on non-neurological shoulders in order to determine and detail the current role of this procedure. PATIENTS AND METHODS: The series included eight patients, five men and three women, mean age 47 years (23-87). The dominant side was operated on in two patients and the non-dominant side in six. Seven patients had had at least one shoulder procedure prior to arthrodesis. Arthrodesis was performed for foreign body reaction on a tendon prosthesis in one patients, posttraumatic head necrosis in two, off-centered degenerative joint disease with full thickness rotator cuff tear in three, and multi-directional instability on degenerative joint disease in two. Arthrodesis was performed via a posterior approach in all patients but one using screw fixation associated with external fixation left in place for 2.5 months on average. RESULTS: All patients except one were satisfied with the outcome (basically because of pain relief). Mean active motion was 75 degrees flexion, 65 degrees abduction (arthrodesis at 20 degrees flexion, 25 degrees abduction and 30 degrees internal rotation). Two groups were identified to analyse the absolute Constant score. The score improved 16 points (from 24 to 40) in the group of patients without instability (pain score improved from 3 to 13) and decreased 14 points (from 66 to 52) in the group with instability (due to decreased motion, the mean motion score declining from 38 to 14). Complications included one radial palsy, one nonunion, and one gravity edema of the upper limb. DISCUSSION AND CONCLUSION: Shoulder arthrodesis is more than a salvage method to reduce pain and gain stability. The objective should be to recover useful function (hand-mouth, hand-perineum, brachio-thoracic function). It should be used when prosthetic arthroplasty is not possible (infectious arthritis, advanced degenerative disease in young subjects, loss of glenoid bone stock, failure after treatment of multidirectional instability with degenerative disease). Shoulder arthrodesis still has rare indications because of the predictability of sustained outcome.

[Arthroplasty for scaphotrapeziotrapezoidal arthrosis using a pyrolytic carbon implant. Preliminary results]. / Traitement de l'arthrose S.T.T. par un Implant en pyrocarbone. Premiers résultats.

INTRODUCTION: The authors propose a scaphotrapeziotrapezoidal (STT) arthroplasty using a discoid pyrocarbon implant. The aim of this prosthesis is to restore the scapho-trapezial mobility without destabilising the carpal bones (unlike with a simple resection of the distal scaphoid pole). METHOD: This technique was used in 15 cases from 1994 to 2002. 12 patients (10 females and 2 males), mean age 65 years) have been reviewed with a mean follow-up of 4 years (1 to 8). Surgical indication was pain refractory to medical treatment (average 8.5 on V.A.S.). Pre-operative mobility showed a loss of radial deviation and dorsal flexion. The severity of the pain did not allow evaluation of the pre-operative strength. Post-operative results were assessed with the EVAL computerised system, static and dynamic X rays were performed in all cases. RESULTS: Pain decreased to an average of 2. The mobility compared to the healthy side showed a slight loss of radial deviation (less than 10 degrees) and in wrist extension (less than 15 degrees). Grip strength was similar to the normal side, even during rapid exchanges. Pinch grip evaluation showed a slight decrease (0.8 kg) which did not compromise normal function of the first ray. No implant luxation was observed in the radiological study. Angular measurements did not show any modification in DISI and other static angles remained unchanged. Dynamic sagital and frontal views confirmed the good mobility of the prosthesis which adjusts its position to the scaphoid movements. CONCLUSION: The good results, the simple surgical procedure, the absence of complications, the lack of a need for any fixation or ligamentoplasty all confirm the advantages of this pyrocarbon implant in the treatment of STT arthrosis. Furthermore, in cases of failure, it is possible to use any other revision procedure.

[Results of rheumatoid wrist surgery (arthrodesis excepted): 16 patients with more than 20 year follow-up]. / Devenir à plus de 20 ans de recul des poignets rhumatoïdes opérés (arthrodèses exclues).

PURPOSE OF THE STUDY: The absence of a medical treatment capable of successfully arresting joint destruction due to rheumatoid arthritis (RA) leaves a large domain for surgical treatment. The purpose of our work was to determine whether a clinical benefit persists in the long term (more than 20 years) despite aggravation of the radiological lesions, after surgical treatment of rheumatoid arthritis of the wrist. MATERIAL AND METHODS: Sixteen patients with RA (13 women and 3 men, mean age 65 years), were reviewed a mean 24.8 years (range 20-33 years) after wrist surgery. Twenty-four wrists were operated for dorsal synovectomy (n=18) and Swanson radiocarpal implant (n=6). Total arthrodeses were excluded. Clinical, functional and standard and stress x-ray data were collected at last follow-up. RESULTS: Residual pain at last follow-up in wrists which had undergone dorsal synovectomy was scored 3.1/10 on the VAS versus 5.6 preoperatively. Three-quarters of the patients stated they were satisfied with the intervention despite very weak force. Revision surgery was required in eight patients after dorsal synovectomy including three which required resection of the ulnar head, left in place after the first surgery, and three for removal of a silicon implant of the ulnar head. This implant was rapidly abandoned in our unit (as in other units). The radiological status worsened in all wrists over time, despite synovectomy. For the Swanson radiocarpal implant, residual pain was only 0.5/10 versus 6.7 preoperatively. Four implants fractured and four developed radiological signs of siliconitis with not clinical expression. Despite these complications, five of the six patients felt favorably about their intervention and the mean Leclerc function score was 78/100. Flexion-extension was 56 degrees on average. The main complaint was the lack of force. CONCLUSION: There is a discordance between radiological and clinical results, a difference which widens with longer follow-up. A clear improvement in the pain score and the moderate functional demands of these patients are probably the reasons for their satisfaction despite radiological degradation. Many desire more wrist force. Our indications have evolved over time with the development after 1980 of the radiolunar arthrodesis procedures that we associate with dorsal synovectomy even in early-stage patients in order to limit radiological degradation and ulnar translation of the carpus. Swanson radiocarpal implants were completely abandoned in 1987 despite favorable clinical results due to the radiological degradation with bone loss and risk of siliconitis. For Simmen III wrists, total arthrodesis remains the only sure and definitive solution.

Glenohumeral arthrodesis in upper and total brachial plexus palsy. A comparison of functional results.

We have compared the functional outcome after glenohumeral fusion for the sequelae of trauma to the brachial plexus between two groups of adult patients reviewed after a mean interval of 70 months. Group A (11 patients) had upper palsy with a functional hand and group B (16 patients) total palsy with a flail hand. All 27 patients had recovered active elbow flexion against resistance before shoulder fusion. Both groups showed increased functional capabilities after glenohumeral arthrodesis and a flail hand did not influence the post-operative active range of movement. The strength of pectoralis major is a significant prognostic factor in terms of ultimate excursion of the hand and of shoulder strength. Glenohumeral arthrodesis improves function in patients who have recovered active elbow flexion after brachial plexus palsy even when the hand remains paralysed.

[Total elbow joint allograft for long term posttraumatic osteoarticular loss. Follow-up results at twelve years]. / Allogreffes d'articulation totale du coude dans les pertes de substance ostéo-articulaire post-traumatiques étendues. Résultats à 12 ans de recul.

PURPOSE OF THE STUDY: Elbow joint allograft (EJA) involving the entire joint (distal humerus, proximal radius and ulna, capsuloligament structures) is a salvage technique proposed in massive bone loss, particularly in young subjects where total elbow prosthesis is contraindicated. We report our experience with seven patients, analyzing the long-term clinical and radiological outcome. MATERIAL AND METHODS: This retrospective study included seven patients, mean age 42 years (21-70). All had experienced severe elbow trauma. Two patients had associated neuromuscular or vascular lesions. All patients underwent at least one surgical procedure on the affected elbow. The preoperative status of the skin cover was crucial. Both longitudinal and circumferential retraction were observed. We used preoperative skin expansion in one patient and a pediculated musculocutaneous latissimus dorsi flap in one other. A posterior and median approach was used conserving tricipital continuity. The ulnar nerve was transposed anteriorly. The allograft was prepared, carefully preserving the capsule and ligaments. Adaptation required cutting the extremities of the humerus and radius and total resection of the radial head except in one patient. Stable plate fixation was completed by an iliac cancellous graft screwed to the humerus and the ulna. The Morrey score was used to assess clinical outcome. The Larsen and Allieu classifications were used to assess radiological outcome. RESULTS: There was one early failure requiring revision for arthrodesis. Assessment of long-term outcome concerned six patients. Mean follow-up was 12 years (7-15 years). The Morrey score improved in six patients and five of them were satisfied. None of the patients complained of invalidating pain and elbow motion was not functional in only one (- 30 degrees - 100 degrees ). For all patients except one, instability was proportional to the duration of the graft and worsened with time. For five out of six patients, significant radiological degradation of the elbow joint was associated with bone lysis which increased with time. DISCUSSION: The allograft acts like a spacer and does not transmit pain impulses. The absence of the pain signal leads to overuse of the grafted joint and osteoarticular destruction. Despite radiological degradation, this procedure provides satisfactory and painless elbow function in most patients. The clinical and radiological features do not follow the same pattern. But we did not have any cases of disassembly or nonunion. Preoperative planning and plastic surgery have enabled us to control the cutaneous portal. We did not have any postoperative infections. Joint allograft is a salvage solution for major osteoarticular loss in young patients desiring conserved joint function and for whom a total elbow prosthesis is contraindicated. It restores bone stock, enables mid-term potential for joint function, and does not compromise surgical revision. CONCLUSION: It remains an exceptional indication which is technically difficult. Resorption of the allograft is constant at long term. Clinically, instability worsen functional outcome. The future for this technique depends on progress in immunology and cryobiology. At the present time, composite total elbow prostheses with an allograft combine the advantages of restored bone stock and arthroplasty.

[Birth and development of the FESUM (European Federation of Hand Emergency Services)]. / Naissance et évolution de la FESUM (Fédération européenne des services d'urgences mains).

The European Federation of Hand Emergency Services (FESUM) was founded in France in 1979 and established all over the country and extended to other European countries in 1989. The aim of this federation is to assure the best possible treatment for hand injuries, thanks to the coordination of the orthopaedic or plastic surgery department which satisfy the standards established and controlled by the federation as well as the development and research in the field of hand trauma and applications of microsurgery. In collaboration with the French Society of Hand Surgery and the French College of Hand Surgery, it fulfills a triple mission of treatment, teaching and research in the specific field of this surgery. The author evokes the present role of the FESUM and the future problems to be solved in order to develop this specialized surgery which plays a major social and economic role.

[Eight days of hand emergencies. Report of the audit carried out at the FESUM centers from June 3 to June 9, 2002]. / Huit jours d'urgences mains. Rapport de l'audit réalisé dans les centres FESUM du 3 au 9 juin 2002.

All the FESUM centers in France, Belgium and Switzerland were invited to participate in this prospective audit, during 1 week in June 2002. In these FESUM centers, the patients are operated by senior hand surgeons or trainees graduated with a microsurgical and a hand surgery University degrees. All acute hand disorders, requiring surgery or not, were to be included. For every case, a standardized form was to be filled. This form included 22 fields concerning the specificities of the patient, the circumstances of the accident, the lesions and initial treatment up to exit of the patient out of the Hand Center. Out of the 43 French centers, 38 (90%) participated in this study, but only 30% in the other French speaking countries. A total of 2360 forms were completed and analyzed, representing a mean of 8 forms per day center (6-147). The population was predominantly active men with a mean age of 31. Manual workers represented 41%, scholars 33%. Most of them came to the Hand Center with a non-specilized vehicle (86%). Emergency medical transportation was required in 130 cases (5.8%). A majority of the patients were treated on an outdoor basis. A 1-day admission concerned 29% of the patients, and 4.6% have been admitted on an indoor basis during several days. Work accident represented 28% of all the cases, while the majority was daily living (62%) or sport (15%) accidents. Closed trauma represented 50% of the cases. Amongst open trauma (974 cases), 862 were simple skin lacerations, 156 skin loss, 140 extensor tendon lacerations, 70 flexor tendon lacerations. A preliminary wound exploration had been performed in a non-specialized center in 124 cases (12%). Complete amputation of some part was observed in 33 cases. In 32%, the initial severity of the lesion led to expect some degree of definitive consequences. Some kind of anesthesia was required in 43% of the cases (local in 41%, troncular in 19%, plexical in 28% and general in 9%). A surgical procedure was performed in 45% of the patients. Microsurgery was necessary in 15%, six of which were replantations. The period between presentation to the Hand Center and treatment was less than 1 day in 95% of the cases. Time of treatment was considered to be delayed in 113 cases (5%). Following this audit, it is considered that the FESUM centers make provision for the care of 120,000 cases per year, 54,000 of which needing a surgical procedure. This may be a small part of the total load of emergency hand surgery throughout the country (generally estimated over 1.4 million), but compares quite favorably with other European studies. We believe that improvement relies essentially on a better orientation of the patients whether they need a simple skill or specialist skill treatment. An information leaflet about orientation of hand trauma has been distributed to non-specialized emergency centers. Hand surgery training must be reevaluated inside the universitary system to avoid a dramatic lack of hand surgeons within a few years. A new audit will be presented next year.

[Nerve entrapment syndrome of the elbow and forearm]. / Syndromes canalaires du membre supérieur au niveau du coude et de l'avant-bras.

In this study we will discuss entrapment of the median, ulnair, radial and lateral antebrachial nerves of the elbow and the forearm. Compression of the nerves may occur when they traverse a tunnel and an incompatibility exists between the diameter of the tunnel and its contents (e.g. nerves, tendons,...). However, at the elbow and the forearm the nerves are also exposed to particularly dynamic compressions. This is due to anatomical relationships changing between the nerve and its surrounding muscles, tendons and aponevroses during the motion of flexion-extension of the elbow and the prono-supination of the forearm. The possibility of this dynamic factor should be thoroughly explored during the examination through appropriate dynamic tests as described in this study.

[Four-bone fusion of the wrist: review of 17 cases at an average 3.4 years follow-up]. / L'arthrodèse des quatre os du poignet.

PURPOSE OF THE STUDY: We reviewed retrospectively outcome after intracarpal arthrodesis for advanced-stage osteoarthritis of the wrist. MATERIAL AND METHODS: Among the 20 patients who underwent a four-bone fusion between 1989 and 1998 in our unit, 17 were available for analysis. Mean age of the study population was 41.5 years. These young patients had an occupational activity and 80% of them were manual laborers. Preoperatively, pain was the main complaint; 95% of the patients considered pain to be invalidating. Grip force was 48.5% compared to the healthy side. Joint amplitudes were limited in all patients: flexion-extension 85 degrees, radio-ulnar inclination 22.5 degrees with 12.5 degrees for the ulnar side. Mean loss of motion compared with the healthy side was 32.5% for flexion-extension, and 44% for radio-ulnar inclination. The preoperartive radiograph showed degenerated capito-lunate joints in 63% of the cases, degenerative scapho-capital joints in 58% and total loss of the radio-scaphoid joint space in 100%. Degeneration was considered to be global in 58% of the wrists. RESULTS: Mean follow-up for the 17 wrists studied was 3.4 years (range 1-10). At last follow-up, 41% of the wrists were pain free, 24% were painful occasionally, and 35% were bothersome for heavy work. The patients did not express any difficulties in daily activities. Grip force was only slightly improved with a 7.5% gain over the preoperative value. Joint motion at last follow-up was, on the average, 70 degrees flexion-extension (40 degrees flexion and 30 degrees extension) and 35 degrees radio-ulnar inclination (17.5 degrees ulnar). Eleven patients (65%) had resumed their occupational activities at the same level two months after surgery. Outcome was deemed satisfactory by 65% of the patients, fair by 17.5%, and poor by 17.5% (3 patients). Radiological fusion was achieved in 16 wrists at a mean 4.5 weeks. Mean carpal height was 0.42 compared with 0.52 for the healthy side and 0.47 preoperatively. There was no significant relationship between carpal height and poor outcome. DISCUSSION: Data in the literature are in agreement with the good results obtained for pain and activity level despite the inconstant effect on grip force and joint amplitude. CONCLUSION: Four-bone fusion is an effective treatment for patients with advanced-stage osteoarthritis of the wrist where the level of degeneration rules out resection. The consequences of total wrist arthroplasty are much more invalidating.

Intercostal nerve transfer classification.

We report a new classification of intercostal nerve transfer. The specific application in brachial plexus reconstruction is described. This method was applied in intercostal nerve transfer to the musculocutaneous nerve in 15 patients. In type 1, "MOTOR to MIXED" transfer one harvest only the intercostal main motor branch which is connected at the trunk of the musculocutaneous nerve, without fascicular specificity. In type 2, "MIXED to MIXED" transfer, based on neural cartography, the main motor branch and its sensitive accessory anterior branches are connected to the musculocutaneous nerve trunk, in attempt to connect the motor fascicules together at the center and also the sensory fascicules together, at the circumference. In type 3, "MOTOR to MOTOR" transfer, the intercostal main motor branch is connected to the musculocutaneous motor branch directly destined to the biceps brachialis. The aim of this work is to evaluate the results between different series.