Outcomes with microsurgery of common peroneal nerve lesions.

OBJECTIVES: The purpose of this retrospective study is to present our results with peroneal nerve lesions, to examine the relative significance of various factors, to assess their effect on outcome, and to establish guidelines of treatment for the microsurgical management of these difficult lesions. METHODS: Over a 33-year period, a total of 62 patients were treated at McGill University and the Microsurgical Research Center, Eastern Virginia Medical School. The clinical records of all patients treated for peroneal nerve lesions were reviewed for retrospective analysis. RESULTS: Of 62 patients, 35 had microneurolysis and nerve decompression of the common peroneal nerve (CPn) as the only surgical procedure while 27 required reconstruction with nerve grafting. Postoperatively muscle power was graded from M + 4 to M - 5 in 27 patients, from M - 4 to M4 in 26 patients, from M - 3 to M + 3 in 8 patients, and from M - 2 to M + 2 in 1 patient. The behavioral video data showed a mean preoperative ankle dorsiflexion of 6.79° ± 5.6 and postoperative ankle dorsiflexion of 37.9° ± 9.3. Overall, excellent functional results were achieved in 27 of 62 patients (43%) with peroneal palsy who underwent microsurgical reconstruction, and good results were observed in 25 patients (40%). CONCLUSIONS: Despite previous widespread pessimism, the surgical repair of CPn lesion is worthwhile, yielding good to excellent results in the majority of patients, after a careful preoperative consultation, establishment of a sound strategy of reconstruction and using aggressive and atraumatic microsurgery.

Morphometric analysis of the effect of scapula stabilization on obstetric brachial plexus paralysis patients.

BACKGROUND: Scapular position and size deficiency is evident in obstetric brachial plexus paralysis (OBPP) patients due to the absence of balanced muscular forces acting on the scapula. Scapula stabilization (SS) procedures aim to restore a balanced musculature and anatomic position and to augment shoulder function and enhance developmental potential. METHODS: Retrospective chart review of 106 patients with OBPP between March 1979 and March 2007 was performed. Forty-one female and 27 male were included in the study. In 38 patients, the paralysis was global, 13 had Erb's paralysis with C7 root involvement; in 18 patients, the lesion was limited to C5 and C6. X-rays were evaluated, and scapula dimensions were manually measured at several stages. Shoulder abduction (SA) and external rotation (SER) outcomes were also recorded. RESULTS: Mean improvement was 85.68° in shoulder abduction and 36.74° in shoulder external rotation. SA and SER improvement was significantly better in those who underwent SS procedures compared to those who did not (mean improvement was increased by 9.15° and 8.54°, respectively). Improvement was noted in all scapular dimensions, in all groups, postoperatively. However, the mean improvement in scapular height, big width, small width, and oblique axis discrepancies was 4.92, 14.04, 12.66, and 13.89 %, respectively, higher in patients who underwent SS procedures compared to those who did not. CONCLUSION: Dimensional discrepancies and functional outcomes are improved by SS procedures. Maximal results are attained in patients who have undergone both primary and secondary shoulder reconstruction before age 2.

Morphometric analysis of the association of primary shoulder reconstruction procedures with scapular growth in obstetric brachial plexus paralysis patients.

BACKGROUND: Obstetric brachial plexus paralysis (OBPP) has been associated with shoulder deformities, scapular growth, and shoulder function impairment. The absence of balanced muscular forces acting on the scapula has been considered responsible for scapula dysplasia and impaired growth as compared with the normal side. Scapula growth impairment may also lead to shoulder and upper extremity dysfunction. This study aims at showing the association of primary nerve reconstruction with the restoration of scapular bone growth potential. METHODS: This is a retrospective review of 73 patients with OBPP who underwent primary shoulder reconstruction. Patients were categorized for assessment and analysis into group A, global paralysis; group B, Erb's palsy; and group C, Erb's palsy with C7 root involvement. Scapular posteroanterior and lateral X-rays were obtained in which four scapula dimensions were manually measured. The growth discrepancy depending on the applied treatment was investigated. RESULTS: The highest improvement was noted in scapular height in the Erb's palsy group who underwent simultaneous neurotization of the suprascapular and axillary nerves. The oblique axis was more improved in the Erb's palsy group while both big and small widths were more improved in the Erb's palsy with C7 root involvement group in patients who underwent concomitant neurotization of the suprascapular and the axillary nerves. Functional improvement correlated positively with growth improvement in all groups and scapular dimensions. CONCLUSION: Scapula growth and shoulder function improvement were higher in patients with Erb's palsy. Simultaneous axillary and suprascapular nerve neurotization provided the best outcome in both functional and growth restoration.

Novel use of platysma for oral sphincter substitution or countering excessive pull of a free muscle.

BACKGROUND: The present study demonstrates our experience with a novel use of the Platysma in facial reanimation, as a balancing procedure by counteracting an overactive free muscle transfer, and improving oral continence by re-establishing the oral sphincter mechanism. MATERIAL AND METHODS: Twelve patients, nine female (75%) and three male (25%), with a mean age of thirty-eight years (range: 2-66) are presented. Of these, in seven patients (58%) who had excessive excursion of the free muscle, the contralateral pedicled platysma was transferred to counteract the excessive pull. Four patients (33%) underwent bilateral platysma transfer for oral sphincter restoration, while one (8%) had ipsilateral platysma transfer. Evaluation of aesthetic and functional results was performed by a panel of three independent observers, and the long term efficacy of the procedure was assessed through a patient questionnaire. RESULTS: All patients demonstrated significant upgrading of their oral competence associated with eating, drinking and smiling, as it was confirmed by the behavioural analysis (p<0.01). Six of the ten patients that were available, responded to the Quality of Life Questionnaire. Five out of six were satisfied with their mouth appearance when they smile and five patients have a regular diet and without drooling. CONCLUSION: A novel use of Platysma transposition is described that can substitute for a paralysed orbicularis oris muscle in restoring oral sphincter function or to counter balance an excessively active free muscle that was previously transferred for smile restoration. This novel Platysma transfer technique is intended to be used as an adjunct to other reanimation procedures.

Reanimation of facial palsy following tumor extirpation in pediatric patients: our experience with 16 patients.

The aim of this study was to present our experience with reanimation of facial palsy (FP) following tumor extirpation in pediatric patients and to analyze the functional outcomes based on different types of procedures performed considering demographic and electrophysiological data of the patients. Sixteen patients with FP post-tumor extirpation who underwent facial reanimation were reviewed. Three independent assessors evaluated the preoperative and postoperative videos using the Terzis' grading scale for eye closure, smile, depressor and overall esthetic and functional outcomes. Preoperative and postoperative electromyographic interpretations and the effect of demographic variables were also evaluated. There was significant improvement in all the patients regarding overall esthetic and functional outcomes (p < 0.0001). Good and excellent overall esthetic and functional outcomes were observed in 62.50% of the patients (n = 10). The difference between preoperative and postoperative EMG results was of statistical significance (p < 0.0001 for each target re-innervated). Better results were observed in younger patients (≤10 years) (p = 0.014) and in early cases (denervation time ≤2 years) (p = 0.033). Functional results were significantly better if surgery was performed within 2 years and the patient was younger than 10 years. Augmentation of the paretic facial musculature in pediatric patients with post-tumor FP was feasible with the use of dynamic and/or static procedures. Advanced microsurgical techniques, such as the use of free muscle transfers, should be kept in mind in late cases (denervation time over 2 years).

FK506 and nerve regeneration: past, present, and future.

Promoting neurological recovery requires strategies that simultaneously provide protection to injured neurons and increase the numbers of neurons that extend axons while inducing more rapid and extensive axon regeneration across long nerve gaps. An agent that facilitates the speed and success of reinnervation will have direct applicability to the clinical management of severe peripheral nerve injuries. The immunosuppressive drug FK506 has been proven to have neuroprotective and neurotrophic actions in experimental models, increasing neurite elongation and accelerating the rate of nerve regeneration in vitro and in vivo. This review examines the role played by FK506, with primary focus on its role as a neurotrophic agent and its potential clinical use as a promoter of neurological recovery following peripheral nerve injuries.

Extratemporal facial paralysis.

PURPOSE: This report summarizes our experience in the management of extratemporal facial paralysis with a variety of reconstructive techniques and explores those parameters which are considered to be useful in achieving better outcomes. METHODS: In all, 56 patients with extratemporal facial paralysis were studied. All the patients had a mean follow-up of 5 years (standard deviation: 3.5). Video evaluation was performed by 3 independent assessors at the required follow-up intervals. RESULTS: The final median score for the partial facial paralysis group was significantly higher (4.175) compared with the complete facial paralysis (3.3), P = 0.007. In this series, the only other factor that appeared to influence the final outcome was the denervation time and not the age group, type of facial nerve injury, or method of repair. CONCLUSION: The concept of dynamic panfacial reconstruction with an individual and tailored to patient's needs approach is demonstrated in all and particularly in bilateral cases.

Experience with 60 adult patients with facial paralysis secondary to tumor extirpation.

BACKGROUND: The aim of this study was to present the authors' experience with facial reanimation in adult patients following tumor extirpation and to analyze the functional outcomes. METHODS: From 1978 to 2006, 60 adult patients underwent facial reanimation for facial paralysis following tumor extirpation. There was one patient with bilateral facial paralysis. Thus, evaluation was carried out in 61 hemifaces. Three independent assessors evaluated the preoperative and postoperative videos using the Terzis grading scale for eye closure, smile, depressor, and overall aesthetic and functional outcomes. Preoperative and postoperative electromyographic interpretations and the effect of demographic variables were also evaluated. RESULTS: There was significant improvement regarding preoperative versus postoperative outcomes for overall aesthesis and function. Good and excellent results were observed in 72.14 percent of the hemifaces (n = 44). The difference between preoperative and postoperative electromyographic results was of statistical significance (p < 0.0001) for each target reinnervated. Better results were observed in younger patients (≤ 35 years) (p = 0.023) and in early cases (p = 0.019). CONCLUSIONS: : The results of this present series illustrate that age and denervation time correlate with the final functional outcome. Cross-facial nerve grafts should ideally be used in patients with denervation time less than 6 months or more than 2 years combined with muscle transfers. In patients with a denervation time between 6 months and 2 years, the use of the babysitter procedure can yield a superior outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Therapeutic strategies in post-facial paralysis synkinesis in adult patients.

BACKGROUND: Facial synkinesis comprises unwanted facial muscle contractions in different facial muscle groups following voluntary ones, in cases of incomplete recovery from facial paralysis. Facial expressivity and function are impaired, and the psychological integrity of the patients is seriously affected. METHODS: Thirty-one adult patients (older than 18 years) presenting with post-facial paralysis synkinesis were included in this study. The mean patient age was 39.6 years and the mean denervation time was 124 months. RESULTS: There were five patient groups. Group A (n = 9) underwent cross-facial nerve grafting and secondary microcoaptations. Group B (n = 8) had cross-facial nerve grafting, secondary microcoaptations, and botulinum toxin type A injections. Group C (n = 6) received cross-facial nerve grafting, secondary microcoaptations, botulinum toxin type A, and selective neurectomies. Group D (n = 2) underwent cross-facial nerve grafting, direct muscle neurotization, and botulinum toxin type A. Group E underwent other means of treating synkinesis (n = 6), such as botulinum injections alone (n = 1), biofeedback alone (n = 2), biofeedback with selective neurectomies and myectomies (n = 2), and biofeedback and botulinum injections (n = 1). Group B had the highest synkinesis improvement (100 percent), followed by groups A and C (66 percent). Functional results were improved, with smile improvement being higher in group C and eye closure being higher in groups A, B, and E. CONCLUSION: Meticulous patient selection and evaluation followed by an individualized form of treatment, most frequently including cross-facial nerve grafting and secondary microcoaptations along with botulinum toxin type A and biofeedback including facial muscle retraining, constitute an effective and reliable methodology with which to combat post-facial paralysis synkinesis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Therapeutic strategies in post-facial paralysis synkinesis in pediatric patients.

UNLABELLED: Synkinetic movements comprise abnormal involuntary contractions of one or more facial muscle groups which follow the desired contraction of another facial muscle group. They are frequently encountered in patients with long standing facial paralysis and seriously affect their psychological status due to the impairment of their facial appearance, function and emotional expressivity. PATIENTS AND METHODS: Eleven pediatric patients (2 male and 9 female) presenting with post-facial paralysis synkinesis were included in the study. Mean age was 10.3±4 years and mean denervation time 72.5 months. RESULTS: Patients underwent the following types of treatment: --Cross facial nerve grafting (CFNG) and secondary microcoaptations with botulinum toxin injection which had an improvement of 100% (3 in the 3 grade synkinesis scale) (n=2). --Cross facial nerve grafting (CFNG) and secondary microcoaptations without botulinum toxin injection which had an improvement of 66%(2 in the 3 grade synkinesis scale) (n=5). --CFNG and direct muscle neurotization with (n=2) or without (n=1) botulinum toxin injection where the improvement was 33%. --Contralateral nasalis muscle myectomy was performed in one patient along with CFNG and secondary microcoaptations which resulted in 66% synkinesis improvement. Biofeedback was invariably undertaken by all patients. Postoperative improvement in eye closure and smile was also noted in the respective cases treated for synkinesis ranging from 25 to 50%, with all patients achieving optimum functional return. CONCLUSION: CFNG with secondary microcoaptations and botulinum toxin injections was found to be a very efficient surgical modality addressing post-facial palsy synkinesis with high improvement in facial function and symmetry. Facial neuromuscular re-education contributes considerably in the treatment.

Our experience with triceps nerve reconstruction in patients with brachial plexus injury.

Although elbow extension is facilitated by gravity, triceps muscle provides elbow joint stability; in patients with brachial plexus injuries stable elbow is necessary for obtaining useful hand function. This study presents the senior author's experience with triceps nerve reconstruction and the functional results in patients with brachial plexus injuries. Outcomes were analyzed in relation to denervation time, severity score, length of the interposition nerve graft and donor nerves used. One hundred and sixty two patients with brachial plexus injury had triceps nerve neurotization and elbow extension recovery between 1978 and 2006. The mean patient's age was 25.45 ± 9.90 years and the mean denervation time was 16.90 ± 26.95 months. Two hundred and thirty two motor donors were used in 156 patients; 6 patients underwent neurolysis; 86 intercostal nerves were transferred in 41 patients. Interposition nerve grafts were used in 130 patients. Results were good or excellent in 31.65% of patients. The age of patients and the severity of the brachial plexus lesion are among the factors that significantly influenced functional results. Intraplexus motor donors are always preferable achieving better functional outcomes than extraplexus donors. Intercostal nerves and the posterior division of contralateral C7 proved preferred donors for elbow extension restoration in multiple avulsions. Although it is difficult to restore strong elbow extension, triceps nerve reconstruction is suggested in brachial plexus management, since it provides elbow stability. Satisfactory elbow extension strength was restored in young patients with high severity score.

Experience with developmental facial paralysis: part II. Outcomes of reconstruction.

BACKGROUND: The purpose of this study was to document the 30-year experience of the authors' center in the management of developmental facial paralysis and to analyze the outcomes of microsurgical reconstruction. METHODS: Forty-two cases of developmental facial paralysis were identified in a retrospective clinical review (1980 to 2010); 34 (80.95 percent) were children (age, 8 ± 6 years) and eight (19.05 percent) were adults (age, 27 ± 12 years). Comparisons between preoperative and postoperative results were performed with electrophysiologic studies and video evaluations by three independent observers. RESULTS: Mean follow-up was 8 ± 6.3 years (range, 1 to 23 years). Overall, outcome scores improved in all of the patients, as was evident from the observers' mean scores (preoperatively, 2.44; 2 years postoperatively, 3.66; final, 4.11; p < 0.001, Kruskal-Wallis test) and the electrophysiologic data (p < 0.0001). The improvement in eye closure, smile, and depressor function was greater in children as compared with adults (p < 0.005, Mann-Whitney test). CONCLUSIONS: Early targeted screening and diagnosis, with prompt specialized treatment, improves the physical and emotional development of children with developmental facial paralysis and reduces the prevalence of aesthetic and functional sequelae of the condition, thus facilitating reintegration among their peers. The experience of this center should serve as a framework for the establishment of accurate and reliable guidelines that will facilitate early diagnosis and management of developmental facial paralysis and provide support and counseling to the family.

Primary restoration of elbow flexion in adult post-traumatic plexopathy patients.

Restoration of elbow flexion is one of the priorities in brachial plexus palsy, as this function brings the hand to the mouth. This study analyses the results of musculocutaneous nerve reconstruction in 194 patients with devastating paralysis. Results were analyzed in relation to denervation time, severity score, length of nerve grafts, and donor nerves used. Between 1978 and 2006, 194 post-traumatic plexopathy patients underwent musculocutaneous nerve reconstruction. 298 motor donors were used in 175 patients while 19 patients had microneurolysis. There were 104 intraplexus motor donors; 124 intercostal nerves were transferred in 39 patients; direct coaptation was performed in 31 patients and three or more intercostals were transferred in 33 patients; 16 patients underwent musculocutaneous to musculocutaneous repair. 144 patients had interposition nerve grafts. The mean follow-up was 4.48 ± 2.78 years. Results were good or excellent (≥M3+) in 52.53% of patients with more than 70° of elbow flexion. Patients, who were operated on less than 4 months from injury, with high severity score, attained significant better results than late cases with multiple root avulsions. Intraplexus donors have direct influence on biceps recovery, achieving significant better results than extraplexus donors. Intercostal nerves are an alternative source in avulsion injuries. The use of 3 intercostals with direct coaptation yielded optimal elbow flexion. Musculocutaneous nerve reconstruction is one of the priorities in upper limb reanimation. Functional outcomes are influenced by the age of the patient, severity of plexus lesion, denervation time, and type of reconstruction. Early surgery is recommended.

Experience with developmental facial paralysis: Part I. Diagnosis and associated stigmata.

BACKGROUND: This study is a thorough literature review of the clinical presentation and evaluation of developmental facial paralysis, with a systematic description of the various stigmata and associated anomalies. It is hoped that this approach will facilitate the differentiation of developmental facial paralysis from other causes of facial paralysis present at birth. METHODS: Forty-two cases of developmental facial paralysis were identified in a retrospective clinical review (1980 to 2010); 34 were children (80.95 percent; age, 8±6 years) and eight were adults (19.05 percent; age, 27±12 years). Thirty-one patients had simple developmental paralysis, and two patients had developmental unilateral lower lip palsy. There were nine patients with associated anomalies or craniofacial syndromes. Five of these patients had multiple cranial nerve deficits. RESULTS: Analysis of the various stigmata revealed significant correlation between the presence of developmental facial paralysis and amblyopia, hypoplastic facial nerve on imaging or surgical exploration, lower alar atresia, and skin changes (i.e., acne), but not the ear abnormalities. CONCLUSIONS: Early targeted screening and diagnosis, with prompt specialized treatment, improves the physical and emotional development of children with developmental facial paralysis and reduces the prevalence of amblyopia and other sequelae of the condition, thus facilitating reintegration among their peers. Given the dramatic presentation of this condition, accurate and reliable guidelines are necessary to facilitate early diagnosis, initiate appropriate therapy, and provide support and counseling to the family.

Developmental facial paralysis: a review.

The purpose of this study is to clarify the confusing nomenclature and pathogenesis of Developmental Facial Paralysis, and how it can be differentiated from other causes of facial paralysis present at birth. Differentiating developmental from traumatic facial paralysis noted at birth is important for determining prognosis, but also for medicolegal reasons. Given the dramatic presentation of this condition, accurate and reliable guidelines are necessary in order to facilitate early diagnosis and initiate appropriate therapy, while providing support and counselling to the family. The 30 years experience of our center in the management of developmental facial paralysis is dependent upon a thorough understanding of facial nerve embryology, anatomy, nerve physiology, and an appreciation of well-recognized mishaps during fetal development. It is hoped that a better understanding of this condition will in the future lead to early targeted screening, accurate diagnosis and prompt treatment in this population of facially disfigured patients, which will facilitate their emotional and social rehabilitation, and their reintegration among their peers.

Secondary shoulder reconstruction in patients with brachial plexus injuries.

Restoration of shoulder stability in post-traumatic plexopathy patients is very important because more distal functions depend on a stable and functioning shoulder. The purpose of this study is to present our experience with secondary surgeries in patients with devastating paralysis. Functional outcomes were analyzed in relation to age, severity score and type of reconstruction. The medical records of 55 post-traumatic plexopathy patients who underwent secondary shoulder reconstruction, by a single surgeon, between 1978 and 2006, were reviewed. 55 patients had 73 procedures, 44 for shoulder abduction and 29 for external rotation. 38 patients underwent secondary surgery to augment shoulder abduction. Trapezius advancement was performed in 14 patients, double free muscle transfer in 18, free latissimus dorsi in 4 and triceps muscle transfer in 2 patients. 26 patients had secondary procedures for enhancement of shoulder external rotation. Dynamic rerouting of latissimus dorsi and teres major was carried out in 18 patients and rotational humerus osteotomy in 11 patients. All patients had improvement of shoulder stability and function. Shoulder abduction reached 40.80 ± 15.93 and external rotation at 24.28 ± 17.90°. Trapezius advancement yielded 41.81 ± 9.02° of abduction. Latissimus dorsi yielded stronger shoulder abduction than adductor longus. Rerouting of latissimus dorsi and teres major attained 22.33 ± 20.31° of dynamic external rotation while humerus osteotomy produced 26.87 ± 10.32 of external rotation. Secondary procedures such as pedicle and free muscles transfers, tendon transfers, and rotational humerus osteotomy augment shoulder stability and function in patients with irreparable paralysis.

Radial nerve injuries and outcomes: our experience.

BACKGROUND: The purpose of this study was to evaluate retrospectively the patients who had undergone radial nerve reconstruction. METHODS: The medical charts of 35 patients with radial nerve lesions and 13 patients with superficial radial nerve lesions who underwent surgical exploration and repair in the authors' center were reviewed. The outcomes were analyzed in relation to various factors, such as age at injury, denervation time, level of injury, length of nerve graft, and type of reconstruction. RESULTS: With regard to the radial nerve, good and excellent motor results were seen in 27 of 35 cases (77.14 percent). Postoperative lateral pinch and grip strength of the affected side were equal to 75.49 percent and 76.42 percent of those of the nonaffected side, respectively. Patient age, level of injury, denervation time, associated nerve injuries, length of nerve graft, and type of surgical reconstruction significantly influenced the functional outcome. For the superficial radial nerve, good and excellent sensory results were seen in 10 of 13 cases (76.92 percent). Postoperatively, pain scores were graded as excellent in 69.23 percent and as good in 23.07 percent of patients. CONCLUSIONS: Better functional results were achieved in younger patients, with denervation time of 3 months or less, in lesions in continuity, in patients without associated nerve injuries, in distal lesions, with neurolysis, and with nerve grafts less than or equal to 5 cm long. Functional outcomes following microsurgical repair of radial nerve injuries are encouraging and should be pursued.

Outcomes of direct muscle neurotisation in adult facial paralysis.

Fifty-seven adult patients with facial paralysis, who underwent direct muscle neurotisation, were reviewed and divided into three categories depending on the function that direct neurotisation was aiming to augment. Group 1 included 30 patients who underwent direct neurotisation for eye closure and blink, group 2 consisted of 23 patients for smile augmentation, and group 3 comprised 31 patients for depressor. The age of the patients ranged from 21 to 74 years. Denervation time (Dt) ranged from 8 months to 42 years. Eight patients had partial facial paralysis, and 49 patients had complete facial paralysis. The results were based on the functional and electromyography (EMG) scoring of the neurotised muscles showing an overall EMG mean improvement of 26.56% in eye closure, 34.47% in smile restoration and 32.67% in depressor function by the procedure. Median improvement in all facial functions was one grade (25%) in theTerzis grading systems regarding the respective facial functions. The prerequisites are Dt less than 6 months and a functional contralateral facial nerve. In cases where Dt is more than 27 months and preoperative EMG's are silent, a free or pedicled muscle should be used to substitute the denervated native facial muscle. Promoting expressivity and augmenting facial muscle function using direct muscle neurotisation are important components in facial reanimation.

Our experience with secondary reconstruction of external rotation in obstetrical brachial plexus palsy.

BACKGROUND: Restoration of shoulder external rotation is very important for upper extremity function. The purpose of this study was to present the authors' experience with secondary restoration of external rotation in patients with obstetrical brachial plexus palsy. METHODS: From 1978 to 2002, 46 children underwent secondary surgery for restoration of external rotation. Outcomes were analyzed in relation to various factors, including the type of procedure, muscle transfer only versus nerve reconstruction and muscle transfer, denervation time, type of injury (Erb versus global palsy), and severity score. In addition, the effect of restoration of external rotation on the final outcome of shoulder abduction was assessed. RESULTS: There was significant improvement in every case (p < 0.01) between preoperatively and postoperatively. The overall mean postoperative Mallet score for the group undergoing muscle transfer only was 3.95, whereas in the nerve reconstruction and muscle transfer group, the score was 3.88 (p >0.05). The resulting gain in external rotation was 99 degrees versus 93.8 degrees. In both populations, a very significant improvement (p <0.0001) was identified in the final outcome of shoulder abduction (109 degrees after muscle transfer versus 48.3 degrees before muscle transfer, and 112 degrees postoperatively after neurotization and muscle transfer versus 43.8 degrees before any surgery). Patients with Erb palsy had a better but not significant result (p >0.05; p = 0.94), compared with those with global palsy in both Mallet score (3.77 versus 3.76) and final active external rotation (81.7 degrees versus 77.6 degrees). CONCLUSION: Secondary surgery for the restoration of external rotation is a rewarding procedure, which also significantly improves the final outcome of shoulder abduction.

Free muscle transfer in posttraumatic plexopathies: part 1: the shoulder.

Microsurgical restoration of shoulder abduction with free muscle transfers is one of the most challenging reconstructions. The purpose of this study was to analyze retrospectively the outcomes of free muscle transfer for shoulder abduction. Since 1981, 22 muscles have been transferred for shoulder abduction in posttraumatic brachial plexopathy. Two techniques have been used: a double muscle transfer of adductor longus and gracilis was used for shoulder abduction and elbow flexion, respectively (n = 18), and latissimus dorsi transfer for shoulder abduction (n = 4). For the double muscle transfer, the mean range of motion of shoulder abduction was found postoperatively to be 30 +/- 24 degrees and the mean muscle grade was to be 2.61 +/- 0.76 (P < 0.001). For latissimus transfer, the mean postoperative muscle grade of the transferred muscle was 3.25 +/- 0.73, and the shoulder abduction was 40 +/- 32 degrees. Free muscle transfer can enhance shoulder abduction after inadequate results from primary reconstruction or in late cases. In this study, all patients achieved a stable shoulder, 53% yielded shoulder abduction against gravity, and 9% achieved abduction to the horizontal level.