Tendon transfer surgery for radial nerve palsy.

Palliative tendon transfer is an integral part of radial nerve palsy treatment. It can be considered in the first weeks when the possibility of nerve repair by direct suture or nerve grafting is not feasible or reasonable. Mostly, it is discussed secondarily when it is too late for nerve surgery and motor recovery cannot be expected, or after failure or incomplete recovery after nerve repair. The goal of tendon transfers is to restore wrist, finger and thumb extension. For wrist extension, the use of pronator teres is well accepted. The best tendon transfer for finger extension is debated. This can be restored doing a flexor carpi ulnaris (FCU), flexor carpi radialis or flexor digitorum superficialis (FDS) to extensor digitorum communis transfer. Regarding thumb extension and abduction, a palmaris longus (PL) or one FDS tendon to the rerouted extensor pollicis longus (EPL) transfer can be performed. If a transfer is done on the EPL without rerouting it, abduction can be restored by doing a tendon transfer to the abductor pollicis longus (APL) or an APL tenodesis. The different tendon transfer options are selected based on the surgeon's preference, and most importantly, discussed with the patients to define the objectives together. The transfer is chosen based on the clinical examination (high or low radial nerve palsy, tendon available for transfer like PL, wrist mobility) and based on the patient's needs and expectations (activities requiring the FCU, finger independence, independence of thumb extension or abduction). If the surgical rules and the postoperative instructions for rehabilitation are followed, tendon transfers for radial nerve palsy regularly produce very satisfactory results.

Palliative surgery for foot drop.

Dysfunction of the common peroneal nerve is the most common mononeuropathy in the lower limb and a source of significant disability for patients. The nerve can be damaged at various levels for various reasons (direct or indirect trauma, extrinsic compression, anatomical variant, endocrine, rheumatological, or neurological disease). Clinical evidence of foot drop with steppage gait is very typical. Conservative treatment should be considered as a first step (avoidance of the contributing factors, functional rehabilitation, foot drop brace ± injection). If properly conducted conservative treatment is not successful, palliative surgery is indicated: either tendon transfer using the posterior tibial tendon or ankle arthrodesis.

Benefits of WALANT in palliative upper limb surgery after nerve injury.

Wide-Awake Local Anesthesia No Tourniquet (WALANT) may be a satisfactory anesthesia alternative for the management of upper limb peripheral nerve palsy sequelae. The main advantages are the possibility of active patient cooperation through intraoperative active mobilization, comfort and cost reduction. The legislation about WALANT in France remains unclear; the modalities of lidocaine epinephrine injection should be redefined. For palliative upper limb surgery, WALANT allows the surgeon to adjust the tension on the tendon transfer intraoperatively. Level 1 studies are needed to evaluate the effectiveness of WALANT relative to standard anesthesia techniques (regional/general anesthesia).

Preoperative imaging assessment of the paralytic upper limb.

Imaging has become an essential tool in the study of the posttraumatic paralytic upper limb, in addition to the clinical examination and electroneuromyography. Upper extremity surgeons must be aware of how these different techniques contribute to the initial and preoperative assessment of nervous injuries. We review the appearance of traumatic nerve damage and muscle denervation during the initial injury assessment, focusing on the main aspects of brachial plexus injuries, paralysis after shoulder dislocation and traumatic damage to the radial nerve. Finally, we discuss the role of imaging for preoperative assessment of musculotendinous and osteoarticular palliative surgeries.

Indications for amputation after traumatic brachial plexus injury in adults: Case report and review of new prosthetic technologies.

Hand amputation can be discussed after traumatic brachial plexus injury when the patient's hand is non-functional, painful and/or insensitive. That indication is more common in English-speaking countries than in European or Latin countries. New prostheses are now on the market and can be used after hand amputation to improve the functional prognosis in well-selected patients. A 26-year-old male was involved in a road accident in January 2016. He had a traumatic brachial plexus injury and underwent nerve surgery to restore the biceps brachii and triceps brachii. One year after nerve transfer, his hand was insensitive and non- functional. After multidisciplinary consultation, it was decided to amputate his hand to replace it with a myoelectric prosthesis. Shoulder subluxation pain and complications associated with an insensitive and heavy arm were improved after hand amputation. Functional outcomes were improved with this revolutionary myoelectric prosthesis technique. The patient was able to use his prosthesis for many daily activities. Selective amputation indications after traumatic brachial plexus injury are a heavy and stiff arm with shoulder subluxation pain and an unusable claw hand. The patient's motivation must be high.

Tendon transfer for trapezius palsy.

The trapezius muscle produces upward scapular rotation that in turn allows complete lateral elevation (abduction) by maintaining the acromiohumeral distance and the deltoideus resting length. Loss of trapezius function leads to shoulder drooping, loss of scapular external rotation with secondary loss of abduction. When conservative treatment has failed and in cases where nerve surgery is not indicated, the most common procedure for treating this condition is the Eden-Lange (EL) procedure. This procedure entails transferring the levator scapulae (LS) to the lateral part of the scapular spine, and the rhomboid major (RM) and minor (Rm) to the infraspinatus fossa to restore the lost trapezius function. Recently, Elhassan et al. proposed a modification of the original EL procedure to recreate the line of pull of the different parts of the trapezius muscle. The modified transfer may yield successful outcomes in patients with trapezius paralysis who failed to improve after well-conducted conservative treatment. Longer follow-up is needed to confirm the stability of the good outcomes of this reconstruction.

Palliative surgery: When? Which technique? Basic principles.

Palliative surgery aims to restore or compensate for the loss of a function for which nerve repairs are no longer or not feasible. It includes tendon transfer, tenodesis, arthrodesis and osteotomy techniques. Palliative surgery is based on several well-established principles that are essential to know. The purpose of this introductory chapter is to review the various basic principles before undertaking palliative surgery.

Scapula alata: Diagnosis and treatment by nerve surgery and tendon transfers.

Scapula alata, also known as winged scapula, can lead to severe upper limb impairment. The shoulders' function is altered because the scapula, which supports the upper limb, is no longer stable. Typical scapula alata is described for serratus anterior palsy; however, any scapulothoracic muscle impairment may lead to scapular winging, particularly trapezius palsy, which is easy to miss, thus needed to be considered as a differential diagnosis. The diagnosis is difficult and based on various clinical tests and a thorough examination as well as electroneuromyography and MRI. The treatment ranges from conservative treatments for spontaneous recovery, nerve surgery including neurolysis, nerve transfers and nerve grafts for acute cases, to tendon transfers for more chronic cases and when nerve procedures are no longer feasible. Tendon transfers in serratus anterior palsy produce excellent results with a high rate of patient satisfaction and are described with the sternal or clavicular head of the pectoralis major; we describe our preferred technique in this article. Tendon transfers in trapezius palsy are performed with the levator scapulae, rhomboid minor and major muscles. Our preferred method is the Elhassan triple transfer. Scapula alata is a frequent and often misdiagnosed condition. Appropriate management can yield excellent results. Patients should be referred right away to specialized centers for surgery if recovery is not spontaneous.

Primary digital localization of extra-axial extra-osseous soft-tissue chordoma: A case report.

We report a case of digital extra-axial extra-osseous soft-tissue chordoma located in a flexor synovial sheath of the little finger of the left hand. Histology-immunohistochemistry (brachyury) analysis after broad en-bloc resection confirmed the diagnosis. Exhaustive MRI assessment of the entire spine, skull and pelvis found no other locations. No recurrence was reported at last follow-up. Hand surgeons should be aware of the diagnosis and treatment of brachyury-positive extra-axial soft-tissue chordomas, whence the importance of recognizing its typical and differential characteristics to guide optimal therapeutic strategy.

Three-dimensional reconstruction of the upper limb from anatomical slices of the Korean visible human: simulation and educational application.

PURPOSE: Digital anatomy is a novel emerging discipline. Use of virtual reality brings a revolution in educational anatomy by improving retention and learning outcomes. Indeed, virtual dissection is a new learning tool for students and surgeons. Three-dimensional vectorial models of the human body can be created from anatomical slices obtained by lengthy series of cryosection from the visible human projects. The aim of this paper is to show how these mesh models could be embedded into an Acrobat® 3dpdf interface, to produce an easy-to-use fully interactive educational tool. METHODS: The learning of this method and its practical application were evaluated on a multicentric cohort of 86 people divided into 3 groups, according to the duration of their training (1, 2 or 3 days, respectively). Participants learned how to use the Mesh tool and how to model 3D structures from anatomical sections. At the end of the training, they were given a survey form. Participants were also asked to rate the training (Poor; Average; Good; Very Good; Excellent). RESULTS: Ninety four percent of the subjects rated the device as excellent and would continue to use digital anatomy in their practice. CONCLUSION: This result is the Diva3d® virtual dissection table, a powerful educational tool for anatomists and students. It could also be the basis of future simulation tools for hand surgeons training.

Applying the WALANT technique to surgical treatment of distal radius fractures.

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) method is a recent anesthesia option for surgery of the upper limbs based on the injection of an anesthetic solution containing adrenaline at the surgical site, hence circumventing tourniquet use. In a prospective study, we compared the functional outcomes using this anesthesia technique with those of the regional anesthesia (RA) technique for the surgical care of distal radius fractures (DRF). From November 2019 to June 2020, a non-randomized, single-center study was conducted with a cohort of 41 patients suffering from a DRF and who received volar plate fixation at a university hospital center. Twenty-one patients had WALANT surgery and 20 had RA with installation of a tourniquet. Over a period of 7 months, the clinical and radiological outcomes as well as the QuickDASH functional score were evaluated. Recovery of wrist function return to work, and analgesic withdrawal for the WALANT group occurred earlier than for the RA group. No noticeable differences were found regarding surgery duration or radiographic results. Using WALANT, functional wrist recovery occurs earlier than with RA. In our study, earlier analgesic stoppage, a quicker return to work and resumption of activity were observed with WALANT. As such, it should become part of the therapeutic arsenal for surgical treatment of DRF.

Lipofibromatous hamartoma of the median nerve and its terminal branches: recurrent branch and ulnar proper palmar digital nerve of the thumb. A case report.

Lipofibromatous hamartoma (LFH) is a rare benign tumor affecting the peripheral nerves, particularly the median nerve. It is characterized by fatty tissue infiltrating the nerve. We report the case of a patient with LFH of the median nerve, recurrent branch and ulnar proper palmar digital nerve of the thumb associated with macrodactyly. It was responsible for hypoesthesia of the thumb's hemi-pulp and secondary carpal tunnel syndrome confirmed by electroneuromyography (ENMG). Diagnosis was suspected based on the MRI findings. The patient underwent surgical treatment consisting of open carpal tunnel release combined with neurolysis of the ulnar proper palmar digital nerve of the thumb. The extraneural LFH tissue was excised also. Forty-five days after surgery, the patient no longer had nocturnal paresthesia. Ninety days after surgery, sensitivity of the thumb pulp was satisfactory. Symptoms of LFH are related to the increased volume of the affected nerve. In the absence of symptoms, abstention seems to be the best option. In case of neurological clinical signs or ENMG abnormality, surgical treatment is indicated to perform neurolysis and excision of extraneural LFH tissue. The diagnosis is based on histological examination of tissue samples.

Fingertip reconstruction by palmar bipedicular island flap in long fingers (modified neurovascular Tranquilli-Leali flap): A dual-center study.

When bone is exposed, fingertip defects may require a flap procedure. Many types are available, with little consensus about which one is best. But each one has its own disadvantages: esthetic (claw nail deformity), neurological (sensory disorders) or functional (stiffness). The purpose of this study was to evaluate a palmar bipedicular island flap (our modification of the Tranquilli-Leali flap) for fingertip reconstruction. We retrospectively analyzed the prospective data of 42 patients with a mean follow up of 16.4 months (6-30 months) operated in two hospital facilities. Thirty-three patients were men. Mean age was 39.5 years (12-83 years) and 24 (57.1%) were smokers. In 23 cases (54.8%), the trauma was work-related. A crush mechanism was identified in 29 patients (69%). According to Allen's classification of fingertip injuries, there were 26 cases of stage II, 14 cases of stage III and 2 cases of stage IV. All procedures were performed on an emergency basis, within 24 hours of the trauma. No claw nail deformity was observed. The mean discrimination in the Weber test was 3.8mm (2-6mm). The mean Total Active Motion (TAM) was 268.3° (255-275°). The patient satisfaction was graded at 8.7 on a 10-point scale. Results were considered as excellent in 15 cases and good in 23 cases. The modified palmar bipedicular island flap makes the old Tranquilli-Leali flap - which has a poor reputation in the hand surgeon community-simpler and safer to use. This flap restores proper balance between skin, bone and nail in Allen stage II and III fingertip amputations.

Hand injury without any deficit: Is systematic surgical exploration justified?

Out of 100,000 inhabitants, 700 to 4000 suffer a hand wound each year. Numerous hand wounds that may not have a clinically evaluated deficit, actually have damage to a major structure after surgical exploration in the operating room (OR). The aim of our study was to evaluate the incidence of major structure damage within a population of patients presenting a hand wound with no deficit on the clinical examination. Every patient older than 12 years, consulting for a wound deeper than the dermis with no clinical signs of major structure damage underwent surgical treatment and exploration of the wound under regional anesthesia in the OR. After each surgery, the surgeon filled out an anonymous study form describing the wound characteristics and the potential findings of major structure damage. Of the 145 wounds with normal clinical examination, we found that 58.6% had a major structure damaged. Given that damage to any major structure in the hand can lead to functional sequela, and the fact that a well-conducted clinical examination by a qualified hand surgeon is not sufficient to eliminate major structure damage, we recommend systematic surgical exploration of hand wounds, even when no clinical deficit is evident. LEVEL OF EVIDENCE III.: Type of sudy: diagnostic study.

Postoperative motor deficits following elbow flexion reanimation by nerve transfer.

We aimed to assess the rate and type of postoperative motor deficits that might be encountered following elbow flexion reanimation using ulnar- and/or median-based side-to-end nerve transfers in patients with brachial plexus injuries. All patients who underwent elbow flexion reanimation between November 2015 and October 2017 at our facility by nerve transfer based on partial harvests of the median and/or ulnar nerves were included. Postoperative clinical assessment was conducted the day after surgery to identify motor deficits in the territory of the harvested nerves. If a clinically noticeable deficit was present, the type and extent of the deficit were noted, and postoperative clinical evaluations were conducted monthly to determine its progression. After reviewing the charts of 27 consecutive patients, 4 patients were found to have a postoperative motor deficit (15%). In all four cases, the deficit was limited to the anterior interosseous nerve (AIN) territory in patients who underwent a double transfer (i.e., ulnar-to-biceps and median-to-brachialis). With clinical impairments of the flexor pollicis longus and/or the flexor digitorum profundus of the index and third fingers initially ranging from grade-0 to grade-3 strength, full recovery to preoperative strength levels occurred in all cases after a mean of 7 months' follow-up. Transient motor deficits may be observed in the AIN territory following elbow flexion reanimation when a median-to-brachialis nerve transfer is associated with the original Oberlin procedure.

Simplified internal fixation of fifth metacarpal neck fractures.

BACKGROUND: Fifth metacarpal neck fractures (boxer's fractures) are common injuries that contribute 20% of all hand fractures. Divergent percutaneous pinning (bouquet fixation) as described by Foucher has gained popularity but is challenging and at times arduous, as it requires the insertion of several slender K-wires into a narrow medullary canal. Here, we report on a simplified technique in which a single thick K-wire is inserted. TECHNIQUE: An 18/10 K-wire is bent at one end then mounted on a drill chuck. The incision is performed and the entry hole created using the K-wire, which is then advanced along the medullary canal. After reduction of the metacarpal head using the Jahss manoeuvre, the K-wire is inserted across the fracture site into the subchondral bone. Any persistent rotational malalignment is corrected by rotating the metacarpal around the K-wire. Immobilisation is by buddy taping covered by a resin guard. METHODS: We collected follow-up data for 30 patients treated using our technique, at a mean age of 32 years. RESULTS: 90 days after surgery, the fracture was healed in all patients. No patients had rotational malalignment. Mean operative time was 14minutes. No complications were recorded. DISCUSSION: The use of a single thick K-wire proved simple, effective, reproducible, and rapid. No rotational malalignment occurred. This technique is faster and easier to perform than divergent pinning with multiple K-wires. CONCLUSION: This technique can be used to treat fifth metacarpal neck fractures.

Two-stage extensor tendon graft using the Paneva-Holevitch procedure: A new technique.

Reconstruction of the extensor tendons remains a therapeutic challenge. Tendon transfers and grafts are a potential source of morbidity at the donor site, and the graft stock is limited. In the index finger, the tendon of the extensor indicis proprius can be anastomosed to the tendon of the extensor digitorum, and then the extensor digitorum tendon turned over after being cut at the forearm. We assessed the feasibility of this reconstruction on 12 upper limbs from 6 cadavers and we report the case of a 24-year-old patient who suffered destruction of the extensor apparatus in the index and middle fingers. For the cadaver study, in each case, the tendon could be moved onto the proximal interphalangeal joint, after having done an anastomosis downstream of the extensor retinaculum. The mean graft length was 13cm (9.7-15.2). This method was used in one clinical case with an excellent outcome. This is a simple technique that is without consequences since the tendons used are already cut, therefore saving a tendon graft. This technique should be part of our therapeutic arsenal.

Accessory extensor pollicis longus: A rare tendon anomaly.

This report provides a complete review of a rare anatomical variation, the accessory extensor pollicis longus (EPL) tendon and its clinical significance. We will describe a case of an asymptomatic accessory EPL that was found incidentally during surgery with a tendon located in the fourth extensor compartment. Pulling on it induced extension of the thumb interphalangeal joint. Very few cases of accessory EPL have been previously reported with various muscle origins and tendon insertions. In the literature, three symptomatic cases of accessory EPL were reported with a tendon running in a compartment other than the fourth. Although this variation is asymptomatic in most cases, knowledge of its existence might be useful in routine procedures to avoid inadvertent tendon damage, or during tendon repair.

Shoulder Arthroplasty Imaging: What's New.

BACKGROUND: Shoulder arthroplasty, in its different forms (hemiarthroplasty, total shoulder arthroplasty and reverse total shoulder arthroplasty) has transformed the clinical outcomes of shoulder disorders. Improvement of general clinical outcome is the result of stronger adequacy of the treatment to the diagnosis, enhanced surgical techniques, specific implanted materials, and more accurate follow up. Imaging is an important tool in each step of these processes. METHOD: This article is a review article declining recent imaging processes for shoulder arthroplasty. RESULTS: Shoulder imaging is important for shoulder arthroplasty pre-operative planning but also for post-operative monitoring of the prosthesis and this article has a focus on the validity of plain radiographs for detecting radiolucent line and on new Computed Tomography scan method established to eliminate the prosthesis metallic artefacts that obscure the component fixation visualisation. CONCLUSION: Number of shoulder arthroplasties implanted have grown up rapidly for the past decade, leading to an increase in the number of complications. In parallel, new imaging system have been established to monitor these complications, especially component loosening.

[Nerve injuries associated with distal radius fractures]. / Lésions nerveuses associées aux fractures de l'extrémité distale du radius.

Nerve damage is a common complication of distal radius fractures. It may be a result of the injury event or be iatrogenic. It is the source of disability and potential handicap. There is little published data on this topic and no study has validated the strategies needed to prevent or manage these nerve-related complications. There is no consensus on treatment. Prevention requires a good knowledge of the various surgical approaches and rigorous fracture fixation technique. The objective of this article is to take stock of recent data from the scientific literature.