Tendon transfer from a re-innervated triceps to the biceps for restoration of elbow flexion in total brachial plexus palsy.

OBJECTIVES: This study aimed to evaluate the outcomes of the tendon transfer from a reinnervated triceps to biceps in the context of total brachial plexus palsy. METHODS: We conducted a retrospective study. Patients had reinnervation of the triceps either by spontaneous recovery or by nerve transfer. Functional results were assessed by strength and range of motion. The level of patient satisfaction was measured on a scale from 0 to 10. RESULTS: Six patients (6 transfers) were included. Two triceps had spontaneous reinnervation and the other four through neurotization of intercostal nerves. All patients recovered strength to M4 in flexion with an average secondary deficit of 10° (5°-15°). The mean level of satisfaction was measured at 7/10 (6-8). CONCLUSIONS: This tendon transfer is a reliable and simple solution for supportive restoration of elbow flexion. Systematic reinnervation of active extension of the elbow should be proposed for the gain in function that it represents but also for the supportive therapeutic opportunity that it offers should nerve surgery for elbow flexion fail.

Reconstruction of delayed distal biceps ruptures with a dermal matrix.

OBJECTIVES: Distal biceps tear is uncommon, with well-recognized risk factors and typical clinical presentation. Delays in surgical treatment lead to several challenges, such as tendon retraction and tendon degeneration. We present a surgical technique using a sterilized acellular dermal matrix, which provides a solution for a challenging pathology. MATERIAL AND METHODS: We present a detailed surgical technique of distal biceps reconstruction with acellular dermal matrix, performed in 4 patients, with an average time to diagnosis of 36 days (range, 28-45 days). Demographics, clinical data, range of motion and subjective satisfaction were collected. RESULTS: At a mean follow-up of 18 months, all 4 patients showed full range of motion and strength, complete recovery and previous work resumed without pain. No complications appeared during this time. CONCLUSIONS: Delayed distal biceps tear reconstruction by acellular dermal matrix showed promising results. Meticulous surgical technique using this matrix provided excellent reconstruction, with very solid anatomical repair and exceptionally good fixation, good clinical outcome and satisfied patients. LEVEL OF EVIDENCE: IV.

Patient-centered management strategy for concurrent musculoskeletal complaints in elbows, shoulders, and neck after an isolated hand/forearm complaint: A prospective interventional study.

The aim was to evaluate patient-reported outcomes before and after a patient-centered management strategy targeting concurrent proximal musculoskeletal complaints (MSCs) in patients with an isolated hand/forearm complaint. A prospective interventional study included 66 patients. Intervention targeting concurrent MSCs was implemented as a patient-centered add-on to standard treatment for primary hand/forearm complaints. The patient-centered management strategy included patient education, individualized exercises, and manual therapy. Patient-reported outcome measures and pain questionnaires regarding the location, frequency, and intensity of pain in hands, elbows, shoulders, and neck were collected at baseline, after the last session of the patient-centered management strategy, and at 3-month follow-up. There were significant improvements in all patient-reported outcomes between baseline and follow-up. DASH scores improved significantly, by 17-29 points on the 3 subscales. There was a significant improvement of 6 points in PCS, 2 points in HADS, and 0.051 points in EQ-5D index. Median pain intensity on NRS decreased from 6 (4-8) to 5 (2.5-7) in hands, 3 (0-6) to 0 (0-3) in elbows, 5 (2-7) to 2.5 (0-5) in shoulders, and 3 (0-6) to 2 (0-3) in the neck, between baseline and discharge. Patients reporting concurrent MSCs in the elbow, shoulder, and neck after an isolated hand/forearm complaint may benefit from patient-centered management comprising patient education, individualized exercises, and manual therapy targeting pain and functional deficits in the upper-limb and neck. LEVEL OF EVIDENCE: IV.

[Evidence-Based Treatment and Differential Diagnoses of Olecranon Bursitis]. / Evidenz-basierte Behandlung und Differenzialdiagnostik der Bursitis olecrani.

Evidence-Based Treatment and Differential Diagnoses of Olecranon Bursitis Abstract. Bursitis olecrani is a common clinical diagnosis that can have systemic, infectious and traumatic causes. In this article we want to present the diagnostics, possible differential diagnoses, complications and the current therapy recommendations as a practical guide.

Ulnar nerve dislocation in ulnar nerve entrapment at the elbow. Influence on surgical outcome.

Our aim was to assess the incidence of symptomatic ulnar nerve dislocation and its influence on surgical outcome after primary and revision surgeries in ulnar nerve entrapment at the elbow (ulnar neuropathy at the elbow (UNE) or cubital tunnel syndrome). The influence of pre- or intra-operative ulnar nerve dislocation on postoperative outcome was assessed in 548 surgically treated cases (548 nerves) from two hand surgery departments reporting to the Swedish National Quality Registry for Hand Surgery, using QuickDASH, a patient-reported outcome measure (PROM), before surgery and at 3 and 12 months postoperatively, and a doctor-reported outcome measure (DROM), grading as "cured-improved "or "unchanged-worsened," at a median follow-up of 3.0 months [IQR, 1.5-6.0]. 109 of the 548 cases (20%) showed documented pre- or intra-operative ulnar nerve dislocation; more often found at revision (35/75, 47%) than at primary surgery (74/473, 16%) (p < 0.0001). Cases with dislocation presented higher QuickDASH scores at 12 months (p = 0.026). A linear regression model, adjusted for age and gender, predicted higher QuickDASH scores at 12 months postoperatively for cases with dislocation (unstandardized B 11.3 [95% CI 0.4-22.2], p = 0.043). DROM grading as unchanged-worsened at a median 3 months predicted worse QuickDASH scores (p < 0.0001) than in cured-improved cases at 3 (unstandardized B, 18.4 [95% CI 9.4-27.3]) and 12 months (unstandardized B, 18.1 [9.1-27.0]). Primary surgeries had better DROM grading than revision surgeries (p = 0.033; cured-improved, 75% and 63%, respectively), but QuickDASH scores did not differ. Presence of a clinically relevant ulnar nerve dislocation resulted in worse outcome, perhaps due to more extensive surgery with transposition. Nerve dislocation needs attention when treating UNE patients.

Palsy of elbow extension.

Elbow extension palsy is generally well tolerated, because when standing up, it is alleviated by gravity. In the case of trunk paralysis or brachial plexus palsy, standing is possible, thus the restoration of active elbow extension improves the hand's positioning above the shoulder, and allows the elbow to be locked in extension, which is necessary during certain activities such as cycling. In these palsy cases, the triceps brachii will be reinnervated by nerve transfers if surgery is performed early enough before irreversible atrophy of the effector muscle sets in. In these situations, secondary tendon transfers are rarely indicated. Few available muscles can be harvested without deleterious consequences on the donor site. Finally, in patients with a very deficient upper limb but with a healthy contralateral limb, when nerve transfers are no longer possible, elbow extension will not be restored. In the tetraplegics using a wheelchair, elbow extension becomes essential for positioning the hand in space and for potentiating the transferable muscles to activate the hand. As nerve transfers have rare indications and are currently being validated in this population, palliative tendon transfers are the reference technique. They must be integrated into an overall upper limb reconstructive surgery program that takes into consideration the potentially usable muscles and the presence of elbow flexion contracture and supination deformity of the forearm. Elbow extension restoration techniques are based on the transfer of two muscles, the posterior deltoid and the biceps brachii. The first is very effective and has very specific requirements, notably good anterior stabilization of the shoulder by the pectoralis major, while the second has broader indications, notably in the case of elbow contracture and inability to stabilize the shoulder anteriorly.

Palliative shoulder and elbow surgery in obstetrical brachial plexus birth palsy.

Palliative surgery in a child with incomplete recovery following obstetric brachial plexus birth palsy (BPBP) is common. Surgical management strategies for BPBP sequelae have the common objectives of decreasing the risk of functional limitations in the long term and improving function. There is no single treatment to deal with the sequelae of BPBP. While there is a myriad of possible clinical presentations, the ages for surgery extend from a 6- to 12-month-old infant to the mature adolescent. Numerous procedures have been described in the literature, ranging from simple soft tissue release to muscular transfers and osteotomies. The indications will depend on a combination of all these factors. In certain cases, an early intervention is recommended to prevent joint deformities, and to allow joint remodeling, often at the shoulder. In other cases, the indications are less clear, thus the expected benefit must be carefully considered. The indications for these operations must meet certain rules to be beneficial for the patient and should only be considered after a comprehensive clinical examination and a commitment from the child and the family to the therapeutic strategy.

Tendon transfers to restore elbow flexion.

Elbow flexion paralysis is one of most significant deficiencies in the upper limb. When secondary to brachial plexus palsy or nerve trunk lesions, restoration of elbow flexion by means of early nerve surgery or palliative transfers should be part of a comprehensive treatment plan. Tendon transfers are indicated in long-standing palsies, in those who are poor candidates for nerve surgery or when the results of nerve surgery are inadequate. A regional pedicled muscle transfer is performed if available. In this case, a "strong" donor is preferred (pectoralis major with pectoralis minor transfer, triceps brachii to biceps brachii transfer, or bipolar latissimus dorsi transfer). A "weak" transfer is indicated in patients who have incomplete recovery of elbow flexion (MRC 2 strength): isolated pectoralis minor transfer, medial epicondylar muscle transfer according to Steindler technique, or advancement of biceps brachii tendon on forearm. When no donor muscle is available, a free reinnervated muscle transfer may be indicated if age and nerve regeneration conditions are favorable.

Implementation of instructional videos improves nursing comfort with commonly encountered urinary catheter care scenarios.

INTRODUCTION: Placement of coudé catheters, manual irrigation of urinary catheters, and management of continuous bladder irrigation (CBI) are routine interventions for which nurses often receive little or no formal education. In this study, our aim was to determine factors associated with higher comfort levels for these catheter-care techniques and to assess whether online instructional videos could be used to improve nursing comfort. MATERIALS AND METHODS: Three 5-minute videos were created to demonstrate proper technique for coudé catheter placement, manual irrigation of a catheter, and management of CBI. An online module with pre- and post-video surveys was created and administered to all nursing staff at MedStar Georgetown University Hospital. RESULTS: A total of 821 nurses participated in this study and completed the online module with both pre-- and post-video surveys. Using a 10-point Likert scale, pre-video median comfort levels for coudé catheter placement, manual irrigation of a catheter, and management of CBI were 5, 6, and 5, respectively. Post-video median comfort levels increased significantly to 9, 8, and 8, respectively (p < 0.001). In the linear regression models, prior formal training was significantly associated with higher baseline comfort levels for all three techniques (p < 0.001). CONCLUSIONS: Prior formal training as well as baseline nursing comfort levels for common catheter related techniques tend to be low and the implementation of simple instructional videos via an online platform may be a useful strategy for improving nursing comfort. This study demonstrates a reproducible strategy for disseminating catheter education for nurses on a larger scale.

Innovative adaptation of the "spare tissues concept" applied for olecranon coverage of a severe burn patient: A case report.

BACKGROUND: The management of bone exposure in patients with extensive burns could be a challenge due to the lack of healthy tissue. In such cases, it could be interesting to use any still healthy tissue initially destined for amputation and use it to cover up another site. We present the case of a sever burn patient for whom we used the only healthy palmar hand skin to cover an olecranon exposure. CLINICAL CASE DESCRIPTION: A 38-year-old man has been admitted in burn victim unit with extensive deep burns on 60% of the total body surface. An exposure of the left olecranon was appeared occurring on a burned area, with absence of healthy local tissues available for coverage. Concomitantly a trans-radial amputation was indicated because of severe digits burns leading to an impossibility to preserve the function of the hand. A palmar skin area was healthy leading to harvested this palmar skin flap pedicled on ulnar vessels. Early post-operative healing was satisfactory and no vascular suffering of the flap has been observed with a total healing at three weeks. CONCLUSION: In any patient the spare tissues concept should be keep in mind when amputation is indicated simultaneously with a problematic of loss of substance coverage to a proximity area. In this case of severe burn patient, we used a palmar skin flap pedicled on the ulnar vessels to cover an olecranon exposure.

Easy tensioning of two-limb ligament reconstructions with docking fixation.

Isometric ligament reconstruction with two graft limbs is used for chronic ligament injuries. Our technique facilitates proper tensioning. It is described in thumb metacarpophalangeal joint ulnar collateral ligament reconstruction. After passing through a tunnel in the base of the phalanx, the two limbs of the graft are docked inside the metacarpal socket. The graft is then fixed under continuous manual tensioning using a Pushlock® anchor. This technique is easy and reproducible; introduction inside the tunnel does not compromise the graft and tensioning is under continuous control. This technique is applicable to any hand, wrist, or elbow ligament reconstruction.

Striking muscle adaptations induced by volume-dependent repeated bouts of low-intensity eccentric exercise of the elbow flexors.

We investigated the effects of repeating 30 low-intensity eccentric contractions with a dumbbell corresponding to 10% maximal isometric strength (10%EC) on muscle strength and hypertrophy, and muscle damage after 30 maximal eccentric contractions (MaxEC) of the elbow flexors. Young men were placed into 1 of 3 experimental groups that performed 10%EC either once, twice a week for 4 (8 bouts) or 8 weeks (16 bouts) before MaxEC, or a control group that performed 2 bouts of MaxEC separated by 2 weeks (n = 13/group). Repeating 16 bouts of 10%EC increased (P < 0.05) maximal voluntary contraction strength (30 ± 21%) and muscle thickness (4.2 ± 2.3%) greater than 8 bouts (16 ± 4%, 1.9 ± 1.3%). Changes in the muscle damage markers after MaxEC were smaller (P < 0.05) for the experimental groups than the control group, and the magnitude of muscle damage protection was greater (P < 0.05) after 16 bouts (65 ± 30%) than 8 bouts (55 ± 33%), followed by 1 bout (34 ± 27%). The protection by 16 bouts was similar (P = 0.81) to that shown by the second MaxEC of the control group. These results showed that 10%EC produced potent muscle adaptation effects accumulatively and conferred muscle damage protection, but 1 bout of 10%EC was still effective for conferring approximately 20% of the protection of that by 16 bouts. Novelty: Repeating low-intensity eccentric exercise induces large increases in muscle strength and hypertrophy. Low-intensity eccentric exercise protects muscle damage induced by maximal eccentric contractions, and the protection is reinforced by repeating it. These are especially beneficial for individuals who are frail and cannot tolerate high-intensity resistance training.

Neuromuscular fatigue of the elbow flexors during repeated maximal arm cycling sprints: the effects of forearm position.

Repeated sprint exercise (RSE) is often used to induce neuromuscular fatigue (NMF). It is currently not known whether NMF is influenced by different forearm positions during arm cycling RSE. The purpose of this study was to investigate the effects of a pronated versus supinated forearm position on elbow flexor NMF during arm cycling RSE. Participants (n = 12) completed ten 10-s maximal arm cycling sprints interspersed by 60 s of rest on 2 separate days using either a pronated or supinated forearm position. All sprints were performed on an arm cycle ergometer in a reverse direction. Prior to and following RSE, NMF measurements (i.e., maximal voluntary contraction (MVC), potentiated twitch (PT), electromyography median frequencies) were recorded. Sprint performance measures, ratings of perceived exertion (RPE) and pain were also recorded. Irrespective of forearm position, sprint performance decreased as sprint number increased. These decreases were accompanied by significant increases in RPE (p < 0.001, ηp2 = 0.869) and pain (p < 0.001, ηp2 = 0.745). Participants produced greater power output during pronated compared with supinated sprinting (p < 0.001, ηp2 = 0.728). At post-sprinting, the percentage decrease in elbow flexor MVC and PT force from pre-sprinting was significantly greater following supinated than pronated sprinting (p < 0.001), suggesting greater peripheral fatigue occurred in this position. The data suggest that supinated arm cycling RSE results in inferior performance and greater NMF compared with pronated arm cycling RSE. Novelty: NMF of the elbow flexors is influenced by forearm position during arm cycling RSE. Supinated arm cycling sprints resulted in worse repeated sprint performance and also greater NMF than pronated RSE.

Luxations traumatiques du coude de l'enfant: aspects épidémiologiques, thérapeutiques et évolutifs / Traumatic dislocations of the elbow in children: epidemiological, therapeutic and progressive aspects

Contexte. Les luxations traumatiques du coude de l'enfant sont des lésions peu fréquentes. Elles nécessitent une prise en charge en urgence afi n d'éviter les complications fonctionnelles. Le but de cette étude était de décrire les aspectsépidémiologiques, thérapeutiques et évolutifs. Méthodes. Il s'agissait d'une étude rétrospective descriptive et analytique des luxations récentes traumatiques du coude. Elle a concerné les patients de moins de 15 ans. Elle a été réalisée du 1er janvier 2016 au 31 décembre 2019 aux urgences de chirurgie. Les données étudiées étaient : les aspects épidémiologiques, thérapeutiques et évolutifs. Un test exact de Fisher a été réalisé pour rechercher les facteurs pouvant infl uencer le résultat fonctionnel. Résultats. Dix-huit luxations traumatiques du coude ont été colligéesdans le service des urgences chirurgicales. Elles représentaient 0,08 % des traumatismes du coude. L'âge moyen était de 10±3,1ans (7-12 ans).Les accidents de jeu étaient l'étiologie la plus fréquente (n=15). La forme convergente postéro-latérale était observée dans tous les cas. La fracture de l'épicondyle médiale (n=3) et la parésie du nerf ulnaire (n=1) étaient associées. Le délai moyen du traitement était de 150±6,8 minutes (60- 360min).Le traitement a été orthopédique. La durée moyennecontention plâtrée était de 25±4,6 jours (21-45 jours).Les résultats fonctionnels globaux selon les critères de Robert étaient excellents dans 14 cas au recul moyen de 06 ±4,7 mois (3-13 mois).Il n'existait aucun lien entre le résultat fonctionnel, le délai de réduction et la présence ou non de lésions associées. Conclusion. Les luxations traumatiques du coude étaient peu fréquentes. La réduction en urgence a donné un bon pronostic fonctionnel.

Coverage of skin defect due to losses of substance in the elbow.

Skin defects of the elbow follow severe trauma or bone exposure after skin necrosis, osteitis, or management of infected pseudarthrosis. The orthopedic and plastic management of these lesions is fundamental. The authors describe the different clinical frameworks that can lead to bone and/or joint exposure. Before, during or at a distance from bone management (external fixation, internal fixation, temporary cementoplasty, bone graft…), they detail the surgical techniques aimed at covering skin defects of the elbow. The authors review simple skin replacement techniques such as Z-plasties, emphasizing the interest of pedicled flaps of the arm and forearm, as well as muscle or fascio-cutaneous flaps, which are able to cover almost all the elbow skin defects.

Clinical outcomes of combined surgical treatment of medial epicondylitis and cubital tunnel syndrome.

Surgical results for treatment of medial epicondylitis and cubital tunnel syndrome are generally satisfactory when performed alone. However, our experience suggests a combined procedure is associated with inferior outcomes. A retrospective review was conducted of consecutive surgical cases of medial epicondylectomy/debridement and ulnar nerve decompression during a single operation at our institution from March 2008 to February 2017 using CPT codes. Thirty combined procedures were identified in 29 patients. Fourteen patients and 15 elbows returned to clinic for evaluation at average 4.3 years after surgery (8 men, 6 women, mean age 45.1 years). A Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, visual analogue pain scale (VAS), and physical examination were performed. The data was stratified by type of ulnar nerve procedure and analyzed. Three of fifteen elbows underwent in situ ulnar nerve decompression, and twelve of 15 had transposition, five subcutaneous and seven submuscular. The mean DASH score for in situ decompression was significantly higher than that of transposition (68.2 vs. 13.1). The average visual pain score for patients whom underwent in situ decompression was significantly higher than that of those with ulnar nerve transposition (8.0 vs. 1.2). All other physical exam measures demonstrated no significant difference between the two groups. In situ ulnar nerve decompression in the setting of medial epicondylectomy/debridement may be associated with inferior clinical outcomes in comparison to ulnar nerve transposition. Further studies are needed to validate the results of our study and inform management.

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.

The use of Tiemann tip catheters for male intermittent self-catheterisation.

Male catheterisation can be difficult to perform, especially in patients with an enlarged prostate gland or other potentially obstructive conditions in the lower urinary tract. Repeated and unsuccessful catheterisations, as well as causing trauma, pain and distress, can cause other conditions such as urethral strictures and 'false passages' (when the catheter is pushed through the urethral wall instead of passing down the urethra), which then require more costly interventions to correct. With an increasingly ageing population these complications are expected to rise, putting added strain on an already stretched health service. This article discusses the use of the Coudé (or Tiemann) tip catheter in patients presenting with these challenging catheterisations and, in particular, male patients performing intermittent self-catheterisation. Device design can help overcome obstructive difficulties, making catheterisation easier, less traumatic and more comfortable for the patient. A survey of 200 nurses working in the urology and continence field was undertaken to understand their awareness and usage of Coudé/Tiemann tip catheters in practice. It was found that many nurses and doctors were unaware of this type of catheter and its advantages and therefore did not use or offer it as an alternative to the more commonly used straight-tipped catheter. In the vast majority of cases when Tiemann tip catheters were used this occurred after failure with a straight-tipped catheter, or they were used with patients with benign prostatic hyperplasia or other potentially obstructive conditions. In many cases, the catheterisation was consultant initiated, despite the fact that intermittent self-catheterisation is instigated and taught mainly by nurses. This survey highlighted the need for better education for nurses and doctors in assessing the alternative catheter tips available to ensure successful catheterisation on first attempt.

"Snapping triceps": A rare and misleading condition - a clinical case report.

Snapping triceps corresponds to subluxation of the medial head of the triceps brachii over the medial epicondyle during active elbow flexion. It is a rare and misleading condition that is often associated with ulnar nerve instability. The latter can result in the snapping triceps being missed. Diagnosis requires a detailed clinical examination. Surgical treatment consists of anterior translocation of the nerve with an adipose flap to stabilize it and transfer of the distal attachment of the medial head of triceps brachii.

Reconstruction of soft tissue defects of the distal third of the arm using a muscle-sparing latissimus dorsi musculocutaneous flap.

Use of a latissimus dorsi (LD) flap has been widely described for upper limb reconstruction. However, donor site sequelae have led to the development of muscle-sparing techniques for the LD flap. We present the technical principles of a muscle-sparing LD flap and its use as a pedicled flap to reconstruct the distal third of the arm.