Selective demyelination of a sciatic nerve allograft after SARS-CoV-2 infection - Case report.

Peripheral neurological complications are seen after SARS-CoV-2 infections. These are mostly immune-mediated such as Guillaine-Barré syndrome or chronic inflammatory demyelinating polyneuropathy. We present a 39-year-old man treated with a right sciatic nerve allotransplantation with subsequent clinical and electrophysiological improvement within 30 months of observation. After SARS-CoV-2 infection, he developed clinical deterioration with selective sciatic nerve demyelination in a nerve conduction study. Nerve conduction velocity returned to previous values within six months of treatment. Intravenous immunoglobulins were used at standard dosage. The inflammatory immune process seemed to be a cause of peripheral demyelination isolated to a nerve allograft with good reaction for intravenous immunoglobulin treatment.

The Relevance of Collision Tests and Quantitative Sensory Testing in Diagnostics and Postoperative Outcome Prediction in Carpal Tunnel Syndrome.

Background: The gold standards for the diagnosis and treatment of carpal tunnel syndrome (CTS) and its outcome are undecided. Using clinical and electrophysiological methods, we tried to establish which fibers achieved full postoperative recovery, and the possibility of using non-standard electrophysiological tests as outcome predictors. Methods: The study group consisted of 35 patients and controls. The Historical-Objective Scale, standard neurography, conduction velocity distribution tests (CVD), and quantitative sensory testing (QST) were performed before and after CTS surgery. Results: Clinical improvement was observed on average in 54.3% of the patients, higher in less advanced CTS. All parameters improved significantly after surgery, except for CVD; most remained worse than in the controls. Only QST parameters fully returned to normal limits. Patient age and CTS severity were important in the estimation of the risk of no improvement. Conclusions: The efficiency of minimally invasive CTS surgery is higher in younger patients with less advanced CTS. Complete recovery was present only in small fibers; larger fibers could most likely be responsible for residual signs. We did not notice any benefits in CTS diagnosis using methods of small fiber assessment. QST seemed to be useful in the diagnosis of residual signs, and in deciding upon possible reoperation.

The Use of Quantitative Sensation Testing to Identify the Physiological Differences Between the Median and Ulnar Nerves.

INTRODUCTION: Similarities in morphology, physiological function, and neurophysiological findings between median and ulnar nerves are not unequivocal. Our previous study confirmed differences in motor fiber parameters between these nerves in healthy persons. We made an attempt to assess and compare the physiological parameters of different sensation modalities (temperature, pain, and vibration) in median and ulnar nerves. METHODS: The study was performed in 31 healthy, right-handed volunteers: 17 women, 14 men, mean age 44.8 ± 15.5 years. Standard sensory conduction tests in the median and ulnar nerves were performed together with the estimation of vibratory, temperature, and warm- and cold-induced pain thresholds in the C7 and C8 dermatomes on the palm, using quantitative sensory testing. RESULTS: There were no statistically significant differences in the standard sensory conduction test in the median and ulnar nerves across the whole group: between right and left hands, and between women and men. We revealed differences in the temperature and pain thresholds between these nerves, mainly in low temperature perception. There were no differences in estimated thresholds between sides or in female and male groups. The vibratory limits did not differ significantly between nerves, and subgroups. CONCLUSION: The study confirmed the differences in the physiological sensory perception between the median and ulnar nerves. The median nerve is more sensitive to temperature stimulation than the ulnar nerve, but simultaneously less sensitive to pain-inducing temperature stimuli. These findings should be considered during the examination of hand nerve pathology.

Brachial plexus injury after shoulder dislocation: a literature review.

Brachial plexus injuries are among the rarest but at the same time the most severe complications of shoulder dislocation. The symptoms range from transient weakening or tingling sensation of the upper limb to total permanent paralysis of the limb associated with chronic pain and disability. Conflicting opinions exist as to whether these injuries should be treated operatively and if so when surgery should be performed. In this review, available literature dedicated to neurological complications of shoulder dislocation has been analysed and management algorithm has been proposed. Neurological complications were found in 5.4-55% of all dislocations, with the two most commonly affected patient groups being elderly women sustaining dislocation as a result of a simple fall and young men after high-energy injuries, often multitrauma victims. Infraclavicular part of the brachial plexus was most often affected. Neurapraxia or axonotmesis predominated, and complete nerve disruption was observed in less than 3% of the patients. Shoulder dislocation caused injury to multiple nerves more often than mononeuropathies. The axillary nerve was most commonly affected, both as a single nerve and in combination with other nerves. Older patient age, higher energy of the initial trauma and longer period from dislocation to its reduction have been postulated as risk factors. Brachial plexus injury resolved spontaneously in the majority of the patients. Operative treatment was required in 13-18% of the patients in different studies. Patients with suspected neurological complications require systematic control. Surgery should be performed within 3-6 months from the injury when no signs of recovery are present.

Use of collision tests to identify physiological differences between the median and ulnar nerves.

INTRODUCTION: Median and ulnar nerves are used in comparative electrophysiological studies. We analyzed the conduction values in these hand nerves in healthy volunteers to find any physiological differences between them. METHODS: We performed standard conduction studies and conduction velocity distribution (CVD) tests with estimation of 3 quartiles in 31 healthy right-handed volunteers (17 women, 14 men) with a mean age of 44.8 ± 15.5 years. RESULTS: The conduction velocities in all quartiles of CVD tests were statistically faster in the ulnar nerve (P < 0.00001), with no differences in the spread of conduction values and no differences between sides. In the ulnar nerve, CVD velocities in all quartiles were faster in the female group (P < 0.05). DISCUSSION: The ulnar nerve has more fibers conducting with high velocities than does the median nerve. Electrophysiological comparisons between hand nerves must be performed carefully. Muscle Nerve 59:470-474, 2019.

Dorsal and volar wrist ganglions: The results of surgical treatment.

BACKGROUND: The wrist, especially its dorsal surface, is the most common location of ganglion cysts in the human body. OBJECTIVES: The purpose of this study was to present our experience in the treatment of wrist ganglions and to evaluate the results obtained with the operative management of this type of lesion. MATERIAL AND METHODS: A total of 394 patients (289 females and 105 males, aged 10-83 years) treated operatively for wrist ganglions between 2000 and 2014 were included in the study. The results of surgical treatment were evaluated after a minimal 2-year-long follow-up in 69.4% of patients operated on for dorsal wrist ganglions and in 70.6% of patients after the excision of volar wrist ganglions. The shape and size of postoperative scar, range of motion of the wrist, grip strength, severity of pain, and presence/absence of ganglion recurrence were assessed. The influence of demographic factors on the risk of recurrence was statistically analyzed. RESULTS: Persistent limitation of wrist palmar flexion was observed in 6 patients after the removal of dorsal wrist ganglions. There were no cases of postoperative grip strength weakening. An unesthetic scar developed in 15 patients after the excision of dorsal wrist ganglions and in 6 patients after the removal of volar wrist ganglions. Postoperative pain was observed in 7 patients with ganglion recurrence and in 17 patients without recurrence. Ganglion cysts recurred in 12.1% of patients treated for dorsal wrist ganglions and in 10.4% of patients operated on for volar wrist ganglions. No influence of patient gender, age, body side, or cyst location on ganglion recurrence was detected. CONCLUSIONS: Operative treatment is a widely recognized method of management of wrist ganglions. The rate of resulting persistent complications is low. Recurrence of ganglion cysts is unpredictable and independent of patient demographic factors. It can be observed even in cases, in which a perfect surgical technique has been used.

Analysis of peripheral nerve and autonomic nervous system function and the stage of microangiopathy in patients with secondary Raynaud's phenomenon in the course of connective tissue diseases.

BACKGROUND: The pathogenesis of secondary Raynaud's phenomenon (SRP) associated with connective tissue diseases (CTD) is not entirely understood. Nervous system dysfunction and microangiopathy are considered to be causes of this pathology. OBJECTIVES: Peripheral and autonomic nervous system function, the stage of microangiopathy, and the relationships between these in patients with SRP were analyzed. MATERIAL AND METHODS: In the study, 20 patients with CTD-related SRP and 30 healthy controls were subject to capillaroscopy, standard conduction velocity tests and conduction velocity distribution (CVD) tests in ulnar and peroneal nerves, heart rate variability (HRV), and sympathetic skin response (SSR) tests. RESULTS: There were no significant differences in the standard motor and sensory conduction velocity tests, or in CVD tests in the ulnar and peroneal nerves in SRP patients compared with the controls. The patients with SRP had a significantly lower SSR amplitude and longer latency in hands and feet. The patients with CTD-related SRP had a significantly lower mean HRV with higher low frequency (LF) values in the spectral analysis and expiration/inspiration ratio (E/I) during deep breathing. There was no correlation between the stage of microangiopathy and neurophysiological test results. CONCLUSIONS: Correct standard conduction velocity and CVD testing in patients with SPR suggest that vasomotor disturbances may occur in CTD regardless of peripheral neuropathy. The lack of relationship between SSR and microangiopathy could confirm that these 2 processes occur independently in patients with CTD-related SRP. Autonomic nervous system impairment together with normal peripheral nerve function suggest the central origin of CTD-related SRP.

Analysis of Patient-Dependent and Trauma-Dependent Risk Factors for Persistent Brachial Plexus Injury after Shoulder Dislocation.

Brachial plexus injuries (BPIs) caused by shoulder dislocation usually have a transient character and tend to resolve spontaneously. However, in some patients the symptoms can persist and require operative intervention. This work aims to determine the risk factors for persistent BPIs resulting from shoulder dislocation. The study comprised 73 patients (58 men, 15 women; mean age: 50 years) treated operatively between the years 2000 and 2016 for persistent BPIs resulting from shoulder dislocation. Patient age, gender, type of initial trauma, number of affected nerves, presence of accompanying injuries, and time interval from dislocation to its reduction were analysed. Elderly patients more often sustained multiple-nerve injuries, while single nerve injuries were more often observed in younger patients. Injury to a single nerve was diagnosed in 30% of the patients. Axillary nerve was most commonly affected. Fracture of the greater tuberosity of humerus coincided with total BPI in 50% of the cases. Longer unreduced period caused injury to multiple nerves. Analysis of our patient group against relevant literature revealed that persistent BPI after shoulder dislocation is more common in older patients. Injuries to ulnar and median nerves more often require operative intervention due to low potential for spontaneous recovery of these nerves.

Volar retinacular ganglions (flexor tendon sheath ganglions) The results of surgical treatment.

Volar retinacular ganglions are the third most common group of all ganglions located in the hand and wrist region. The purpose of this work is to present our experience in management and the results of operative treatment of volar retinacular ganglions. One-hundred-and-seven patients were operated-on for volar retinacular ganglions between 2000 and 2014. One-hundred-and-eight ganglions were resected. Complications which were observed in five patients postoperatively (digital nerve irritation, restricted range of motion of digital joints) resolved within several weeks. At final follow-up, no ganglion recurrence, impairment of finger mobility, innervation or blood supply were observed in any of the patients.

Chitosan and its composites: Properties for use in bone substitution.

For many years, research has been carried out on finding an ideal bone substitute. Chitosan (CTS) is a naturally occurring polysaccharide, obtained mainly from, inter alia, the shells of crustaceans. It is characterized by its high level of biocompatibility, biodegradability and antimicrobial properties as well as its support in the healing of wounds. Chitosan, due to its ability to form porous structures, can be used in the production of scaffolds used in the treatment of bone defects. There are numerous studies on the use of CTS in combination with other substances which aim to improve its biological and mechanical properties. The combination of chitosan with the calcium phosphate hydroxyapatite (HAp) has been extensively tested. The objective of the current studies is to verify the properties of scaffolds consisting of chitosan and other substances like polybutylene succinate, human bone marrow mesenchymal stem cells (hBMSCs), collagen, alginate, transforming growth factor - ß (TGF-ß), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF) or bone morphogenetic proteins (BMP). The aim of the current research is to develop a scaffold with sufficiently good mechanical properties. Trials are underway with many of the biological and synthetic components affecting the biological properties of chitosan. This will allow for the creation of a substitute that fully meets the conditions for an ideal artificial bone.

The role of chitin and chitosan in peripheral nerve reconstruction.

Chitin is a natural polysaccharide commonly found in nature and chitosan is its partially deacetylated derivative. The properties of both biopolymers allow their wide use in medicine and various industries. This paper presents the possibilities offered by chitin and chitosan for the creation of neurotubes utilized in peripheral nerve repair procedures. In the initial part of this manuscript, experimental studies on both polysaccharides carried out by numerous authors have been presented and their results have been discussed. Further, basic information on Reaxon® Nerve Guide, being the first chitosan tube approved for clinical use, is provided. Finally, existing limitations in the optimal use of chitosan tubes in peripheral nerve reconstruction have been pointed out. It is expected that modification of the properties of chitosan itself as well as enriching neurotubes with components of extracellular matrix, cells, growth factors and filaments will further improve the results of nerve regeneration obtained with chitosan-based nerve conduits.

Position of Immobilization After First-Time Traumatic Anterior Glenohumeral Dislocation: A Literature Review.

Anterior glenohumeral dislocation affects about 2% of the general population during the lifetime. The incidence of traumatic glenohumeral dislocation ranges from 8.2 to 26.69 per 100 000 population per year. The most common complication is recurrent dislocation occurring in 17-96% of the patients. The majority of patients are treated conservatively by closed reduction and immobilization in internal rotation for 2-3 weeks. However, no clear conservative treatment protocol exists. Immobilization in external rotation can be considered an alternative. A range of external rotation braces are commercially available. The purpose of this work was to review the current literature on conservative management of glenohumeral dislocation and to compare the results of immobilization in internal and external rotation. A comprehensive literature search and review was performed using the keywords "glenohumeral dislocation", "shoulder dislocation", "immobilization", "external rotation", and "recurrent dislocation" in PubMed, MEDLINE, Cochrane Library, Scopus, and Google Scholar databases from their inceptions to May 2016. Three cadaveric studies, 6 imaging studies, 10 clinical studies, and 4 meta-analyses were identified. The total number of 734 patients were included in the clinical studies. Literature analysis revealed better coaptation of the labrum on the glenoid rim in external rotation in cadaveric and imaging studies. However, this tendency was not confirmed by lower redislocation rates or better quality of life in clinical studies. On the basis of the available literature, we cannot confirm the superiority of immobilization in external rotation after glenohumeral dislocation when compared to internal rotation. A yet-to-be-determined group of patients with specific labroligamentous injury pattern may benefit from immobilization in external rotation. Further studies are needed to identify these patients.

Results of Operative Treatment of Brachial Plexus Injury Resulting from Shoulder Dislocation: A Study with A Long-Term Follow-Up.

BACKGROUND: Injury to the infraclavicular brachial plexus is an uncommon but serious complication of shoulder dislocation. This work aims to determine the effectiveness of operative treatment in patients with this type of injury. METHODS: Thirty-three patients (26 men and 7 women; mean age, 45 years and 3 months) treated operatively for brachial plexus injury resulting from shoulder dislocation between the years 2000 and 2013 were included in this retrospective case series. Motor function of affected limbs was assessed pre- and postoperatively with the use of the British Medical Research Council (BMRC) scale. Sensory function in the areas innervated by ulnar and median nerves was evaluated with the BMRC scale modified by Omer and Dellon and in the remaining areas with the Highet classification. Follow-up lasted 2-10 years (mean, 5.1 years). RESULTS: Good postoperative recovery of nerve function was observed in 100% of musculocutaneous, 93.3% of radial, 66.7% of median, 64% of axillary, and 50% of ulnar nerve injuries. No recovery was observed in 5.6% of median, 6.7% of radial, 10% of ulnar, and 20% of axillary nerve injuries. Injury to a single nerve was associated with worse treatment outcome than multiple nerve injury. CONCLUSIONS: Obtaining improvement in peripheral nerve function after injury resulting from shoulder dislocation may require operative intervention. The type of surgical procedure depends on intraoperative findings: sural nerve grafting in cases of neural elements' disruption, internal neurolysis when intraneural fibrosis is observed, and external neurolysis in the remaining cases. The outcomes of surgical treatment are good, and the risk of intra- and postoperative complications is low.

The giant cell tumour of the proximal phalanx of the thumb treated by a 2-stage operation.

We present a 29-year-old woman who was treated for a giant-cell tumour of her thumb. Surgical treatment was performed in two stages. In the first stage, the tumour was removed and the first metacarpal and distal phalanges were fixed by an external fixator. In the second stage of reconstruction of the thumb, a cortico-cancellous bone graft from the iliac crest, an external fixator and double arthrodesis were used. This two-stage procedure provides the possibility for confirming the diagnosis and appropriate treatment choice and minimizes the risk of recurrence.

Ganglions of the hand and wrist: Retrospective statistical analysis of 520 cases.

BACKGROUND: Ganglions constitute the most common tumor type of the hand and wrist region. They have a non-neoplastic character and affect patients of all ages. OBJECTIVES: The purpose of this work was to analyze the epidemiological data of a representative group of patients diagnosed with ganglions of the hand and wrist. MATERIAL AND METHODS: Five-hundred-and-twenty patients operated on for ganglions of the hand and wrist between the years 2000 and 2014 were included in the study. For the statistical analysis, STATISTICA v. 10 was used. Categorical data was analyzed using the χ2. The distribution of two and more independent samples was compared through the Mann-Whitney U test and Kruskal-Wallis test followed by pairwise comparisons for significant test statistics, respectively. RESULTS: In the studied group of patients, ganglions affected females more often than males, with a 2.8 : 1 ratio. No statistically significant differences in age distribution between women and men (median age 38 vs. 40 years) were found. Ganglions affected both sides of the body with comparable equality. Wrist ganglions predominated (76%). The patients diagnosed with hand ganglions were statistically significantly older (p < 0.001), and the right hand was affected more often (p = 0.003). A statistically significant difference in age distribution between the patients with DWG (dorsal wrist ganglions) and VRG (volar retinacular ganglions) was observed (p < 0.001). DWG affected the left side (p = 0.003) and VRG the right side (p = 0.005) of the body more often. CONCLUSIONS: Statistical analysis of our patients confirmed much of the previously published data. Although the diagnosis and treatment of ganglions of the hand and wrist are relatively uncomplicated, the pathophysiology of their formation is still waiting to be thoroughly explained.

Long-Term Results of Neurectomy Through a Dorsal Approach in the Treatment of Morton's Neuroma.

BACKGROUND: Morton's neuroma, a painful enlargement of the plantar digital nerve between the metatarsal heads, is a common cause of metatarsalgia. The etiology and treatment are still a controversial matter. OBJECTIVES: The objective of this study was to evaluate the long-term follow-up results of neurectomy through a dorsal approach and to identify prognostic factors that can affect the final outcome. MATERIAL AND METHODS: The study included 41 patients who were treated for Morton's neuroma. Their average age was 44 years (range: 25-69 years). The average follow-up time was 7.4 years (range: 5-12 years). Surgery was performed through a dorsal approach. The clinical evaluations, visual analog scale (VAS) scores and American Orthopedic Foot and Ankle Society (AOFAS) scores were assessed. RESULTS: The mean preoperative AOFAS score was 39.4 ± 7.84 and the mean postoperative AOFAS score was 83.4 ± 12.1. The mean preoperative VAS scale was 7.04 ± 1.4 and the mean postoperative VAS scale was 1.4 ± 0.8. There were 31 patients (76%) with very good results in the subjective and objective patient assessments; six (15%) had good results; one (2%) had satisfactory results and three (7%) had poor results. Statistically significant differences in the results between single and multiple neuromas were found, depending on the size of the neuromas and the duration of the symptoms. There were no statistically significant differences depending on the time between surgery and assessment, on steroid injections before operation or on the duration of preoperative conservative treatment. CONCLUSIONS: Despite the development of less invasive techniques and very good outcomes in a short period of time, long-term results have shown that neurectomy is still useful in the treatment of Morton's neuroma. The results of the study show that the outcome does not change during the postoperative follow-up period. The best results were achieved in the case of single neuromas larger than 3 mm that were resected within 12 months of the onset of symptoms.

Evaluation of Soft Tissue Reaction to Corundum Ceramic Implants Infiltrated with Colloidal Silver.

BACKGROUND: Corundum ceramic is a biomaterial used as a bone graft substitute. Silver is a well known antiseptic substance with many practical, clinical applications. OBJECTIVES: The aim of this study was to estimate soft tissue (in vivo) reaction to a new kind of ceramic implants. In our experiment, we examined the soft tissue reaction after implantation of corundum ceramic infiltrated with colloidal silver in the back muscles of 18 Wistar rats. The use of colloidal silver as a coating for the implant was designed to protect it against colonization by bacteria and the formation of bacterial biofilm. MATERIAL AND METHODS: In our study, based on the experimental method, we performed implantation operations on 18 Wistar rats. We implanted 18 modified ceramic implants and, as a control group, 18 unmodified implants. As a follow up, we observed the animals operated upon, and did postoperative, autopsy and histopathological examinations 14, 30, 90 and 180 days after implantation. RESULTS: We didn't observe any pathological reactions and significant differences between the soft tissue reaction to the modified implants and the control group. CONCLUSIONS: Lack of pathological reaction to the modified implants in the living organism is the proof of their biocompatibility. This is, of course, the first step on the long path to introduce a new kind of biocompatible ceramic implant with antiseptic cottage. Our experiment has an only introductory character and we plan to perform other, more specific, tests of this new kind of implant.

Effect of Collateral Sprouting on Donor Nerve Function After Nerve Coaptation: A Study of the Brachial Plexus.

BACKGROUND The aim of the present study was to evaluate the donor nerve from the C7 spinal nerve of the rabbit brachial plexus after a coaptation procedure. Assessment was performed of avulsion of the C5 and C6 spinal nerves treated by coaptation of these nerves to the C7 spinal nerve. MATERIAL AND METHODS After nerve injury, fourteen rabbits were treated by end-to-side coaptation (ETS), and fourteen animals were treated by side-to-side coaptation (STS) on the right brachial plexus. Electrophysiological and histomorphometric analyses and the skin pinch test were used to evaluate the outcomes. RESULTS There was no statistically significant difference in the G-ratio proximal and distal to the coaptation in the ETS group, but the differences in the axon, myelin sheath and fiber diameters were statistically significant. The comparison of the ETS and STS groups distal to the coaptation with the controls demonstrated statistically significant differences in the fiber, axon, and myelin sheath diameters. With respect to the G-ratio, the ETS group exhibited no significant differences relative to the control, whereas the G-ratio in the STS group and the controls differed significantly. In the electrophysiological study, the ETS and STS groups exhibited major changes in the biceps and subscapularis muscles. CONCLUSIONS The coaptation procedure affects the histological structure of the nerve donor, but it does not translate into changes in nerve conduction or the sensory function of the limb. The donor nerve lesion in the ETS group is transient and has minimal clinical relevance.

Causes of Secondary Radial Nerve Palsy and Results of Treatment.

BACKGROUND The aim of this study was to analyze the causes that lead to secondary damage of the radial nerve and to discuss the results of reconstructive treatment. MATERIAL AND METHODS The study group consisted of 33 patients treated for radial nerve palsy after humeral fractures. Patients were diagnosed based on clinical examinations, ultrasonography, electromyography, or nerve conduction velocity. During each operation, the location and type of nerve damage were analyzed. During the reconstructive treatment, neurolysis, direct neurorrhaphy, or reconstruction with a sural nerve graft was used. The outcomes were evaluated using the Medical Research Council (MRC) scales and the quick DASH score. RESULTS Secondary radial nerve palsy occurs after open reduction and internal fixation (ORIF) by plate, as well as by closed reduction and internal fixation (CRIF) by nail. In the case of ORIF, it most often occurs when the lateral approach is used, as in the case of CRIF with an insertion interlocking screws. The results of the surgical treatment were statistically significant and depended on the time between nerve injury and revision (reconstruction) surgery, type of damage to the radial nerve, surgery treatment, and type of fixation. Treatment results were not statistically significant, depending on the type of fracture or location of the nerve injury. CONCLUSIONS The potential risk of radial nerve neurotmesis justifies an operative intervention to treat neurological complications after a humeral fracture. Adequate surgical treatment in many of these cases allows for functional recovery of the radial nerve.

Chemical Substances Used in the Treatment of Ganglions Located in the Hand and Wrist.

The aim of this work was to compare different chemical substances used in the treatment of ganglions located in the hand and wrist region. Their basic properties and mechanisms of action have been described. Moreover, the risks associated with the use of particular substances have been highlighted and potential complications connected with their administration have been discussed. On the basis of the available literature, the results of ganglion aspiration treatment followed by an injection of a chemical substance into the cyst cavity have been assessed. In the authors' opinion, due to the existing risk of complications associated with this treatment, as well as the relatively high rate of ganglion recurrence, this procedure should only be performed by qualified medical personnel. The authors recommend observation in cases of asymptomatic ganglions of the hand and wrist, and operative treatment in cases in which pain, restriction of limb mobility and weakening of handgrip strength are observed.