BACKGROUND:In treating patients with brachial plexus injury, there are no comparative data on the outcomes of nerve grafts or nerve transfers for isolated upper trunk or C5-C6-C7 root injuries. The ...purpose of our study was to compare, with systematic review, the outcomes for modern intraplexal nerve transfers for shoulder and elbow function with autogenous nerve grafting for upper brachial plexus traumatic injuries.
METHODS:PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for studies in which patients had surgery for traumatic upper brachial plexus palsy within one year of injury and with a minimum follow-up of twelve months. Strength and shoulder and elbow motion were assessed as outcome measures. The Fisher exact test and Mann-Whitney U test were used to compare outcomes, with an alpha level of 0.05.
RESULTS:Thirty-one studies met the inclusion criteria. Two hundred and forty-seven (83%) and 286 (96%) of 299 patients with nerve transfers achieved elbow flexion strength of grade M4 or greater and M3 or greater, respectively, compared with thirty-two (56%) and forty-seven (82%) of fifty-seven patients with nerve grafts (p < 0.05). Forty (74%) of fifty-four patients with dual nerve transfers for shoulder function had shoulder abduction strength of grade M4 or greater compared with twenty (35%) of fifty-seven patients with nerve transfer to a single nerve and thirteen (46%) of twenty-eight patients with nerve grafts (p < 0.05). The average shoulder abduction and external rotation was 122° (range, 45° to 170°) and 108° (range, 60° to 140°) after dual nerve transfers and 50° (range, 0° to 100°) and 45° (range, 0° to 140°) in patients with nerve transfers to a single nerve.
CONCLUSIONS:In patients with demonstrated complete traumatic upper brachial plexus injuries of C5-C6, the pooled international data strongly favors dual nerve transfer over traditional nerve grafting for restoration of improved shoulder and elbow function. These data may be helpful to surgeons considering intraoperative options, particularly in cases in which the native nerve root or trunk may appear less than optimal, or when long nerve grafts are contemplated.
LEVEL OF EVIDENCE:Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.
Medial epicondylitis is a tendinosis found commonly in throwing and golfing athletes. Although there are choices for nonsurgical treatments, when these fail, surgical intervention can be considered. ...When surgical treatment is performed, the objective is to debride the diseased tissue from the epicondyle. The purpose of this study was to clarify the locations and size of the common flexor tendons and medial collateral ligament (MCL) relative to each other and to the posterior ridge of the medial epicondyle.
The common flexor tendons and MCL were dissected and reflected their origin on the medial epicondyle in six cadaver elbows. Measurements were taken from the posterior and distal ridges of the medial epicondyle with respect to the humerus. Each origin was also measured for its height and width.
The flexor carpi ulnaris origin starts at a mean of 4.2 mm from the posterior ridge of the medial epicondyle and extends anteriorly an average of 4.8 mm. The flexor carpi radialis starts at a mean of 4.2 mm from the posterior ridge and extends anteriorly an average of 7.4 mm. The pronator teres begins at a mean of 4.6 mm from the posterior ridge and extends an average of 5.7 mm anteriorly. The MCL starts at an average of 10.4 mm from the posterior ridge and extends 5.2 mm anteriorly.
The measurements found have allowed the creation of a map of the specific common flexor tendon origins and their sizes on the medial epicondyle, as well as their position relative to the MCL.
A surgeon may debride 1 cm anteriorly from the posterior ridge of the medial epicondyle to safely address the affected tissues and ensure the safety and integrity of the MCL.
Reconstruction of the ulnar collateral ligament (UCL) of the thumb metacarpophalangeal joint is commonly performed for chronic injuries. This study evaluates the anatomic feasibility of using a part ...of the adductor pollicis tendon to reconstruct UCL.
Ten cadaveric arms were dissected to evaluate the relationship between the insertions of UCL and the adductor pollicis. A slip of the adductor pollicis was divided from the tendon and transposed dorsally. The dissected tendon was deemed sufficient for reconstruction if it could be reflected to the footprint of the UCL origin. The size of the adductor pollicis slip was then compared with that of UCL.
The dissected slip of the adductor pollicis could be fully reflected proximally to the UCL origin in all the specimens, and the insertion was also found to be closely approximated to the UCL insertion, averaging 2 mm distally and 0.6 mm dorsally.
A sufficiently sized partial adductor pollicis tendon can be obtained to reconstruct UCL of the thumb metacarpophalangeal joint, and the location of the adductor pollicis insertion closely approximates that of the UCL insertion.
The anatomic relationship evaluated in this study relates to a recently described method of the reconstruction of UCL of the thumb metacarpophalangeal joint that does not require free tendon harvest. This study shows that the technique is anatomically feasible.
In patients with segmental nonunion of the distal radius, the distal ulna and distal radioulnar joint may not be salvageable. As an alternative to a vascularized free fibula, a pedicled distal ulna ...vascularized graft is a useful salvage technique. The procedure relies on the vascular bundle of the pronator quadratus and the dorsal oblique arterial anastomosis between the anterior and posterior interosseous arteries running along the interosseous membrane as the pedicle. We present 3 patients who received a distal ulna vascularized graft with concomitant wrist arthrodesis for distal radius segmental nonunion after complex distal radius fracture. This technique provides a local pedicled graft that may be a simpler, more reliable, and less technically demanding alternative.
Background
Reconstruction of the radial collateral ligament (RCL) of the thumb metacarpophalangeal (MP) joint is commonly performed for chronic injuries. This study aims to evaluate the anatomical ...feasibility and reliability of using the abductor pollicis brevis (APB) tendon to reconstruct the RCL.
Methods
Ten cadaver arms were dissected to evaluate the relationship between insertions of the RCL and APB. A slip of the APB was divided from tendon and reflected proximally. The dissected tendon was deemed sufficient for reconstruction if it could be reflected to the footprint of the RCL origin. The size of the dissected APB slip was then compared with that of the RCL.
Results
The dissected slip of the APB could be fully reflected proximally to the RCL origin in all specimens. The APB insertion was also found to be closely approximated to the RCL insertion, averaging 2.1 mm distal and 1.8 mm dorsal. Significant differences existed between the lengths (P < .001) of the APB slip and RCL, with no significant difference in widths (P = .051).
Conclusions
A sufficient APB tendon slip can be obtained to reliably reconstruct the RCL of the thumb MP. The location of the APB insertion closely approximates the RCL insertion.
Mechanistic cadaver study.
Patients in groups 4 and 5 of the International Classification for Surgery of the Hand in Tetraplegia have a few options for tendon transfer donors, but in general the ...needs for reestablishing motor power exceed the donor options, such that any increase in the number of potential transfers can enhance function. Although transfer of brachioradialis (BR) in these patients is well-established, pronator teres (PT) may also be a suitable donor due to its strength and excursion. It has not been extensively studied in this role, possibly because of concerns about its expendability as the major agonist of forearm pronation. The purpose of this study is to quantify forearm pronation capability pre- and post-tendon transfer of PT to flexor pollicis longus (FPL) in a cadaver model.
Surgery center in Indianapolis, USA.
Five cadaver arms were evaluated for pronation capability against gravity before and after PT to FPL tendon transfer. In both stages, the arms were also assessed for the pronation forces produced at the wrist when pulling PT with 25, 50, and 75 N of force. With each force, the arms were tested in full supination and neutral position.
All five arms were capable of pronating against gravity before and after the PT to FPL tendon transfer. Following the transfer, pronation force at the wrist decreased by 1-5 N, but the change was not statistically significant.
PT to FPL tendon transfer produces thumb flexion while retaining the forearm's ability to pronate and would likely retain good clinical function, freeing up BR to recreate active finger flexion or extension.
Purpose For scientists, authorship is academic currency. Authorship characteristics have been studied in a subset of the surgical and medical literature, but trends in the specialty of hand surgery ...have not yet been investigated. Specifically, a longitudinal analysis of number, educational training, sex, and geographical origin of authors has not been conducted. We explored the progression of authorship of scientific articles in a leading hand surgery journal. Methods We recorded number of authors, number of references, degrees, and sex of the first and senior authors as well as geographical origin of the corresponding author in The Journal of Hand Surgery in 1985, 1995, 2005, and 2015. All original work was analyzed. Results A total of 892 articles were reviewed. The mean number of authors per article increased significantly from 2.6 in 1985 to 3.9 in 2015 and the number of references increased significantly from 13.7 in 1985 to 22.6 in 2015. There was a significant increase in the proportion of first authors with an MD/PhD, PhD, master’s or bachelor’s degree since 1985. During that same time period, a decrease in the proportion of first authors who held solely an MD was seen. There was a significant increase in proportion of the number of last authors with an MD/PhD, PhD or Master’s degree in that same time period. There has been significant growth in publications originating from the “Far East” and “Other” regions, with 4.2% and 5.0% of publications, respectively, in 1985 having increased to 10.3% and 7.4% of publications, respectively, in 2015. Female first authorship significantly increased over the study period from 7.9% in 1985 to 22.1% of publications in 2015. Conclusions There has been a significant increase in number of authors per article in The Journal of Hand Surgery . Similar to other studies, we noted shifts in the degrees most commonly held by authors, an increase in references per article, and a greater representation of international authors in the hand surgery. In addition, the proportion of manuscripts written by female authors has increased in the past 30 years, with the largest increase occurring between 2005 and 2015. Clinical relevance This manuscript strives to provide further insight into the changing characteristics of authors contributing to the hand surgery literature. With increased pressure to publish in academia, it is important to understand how publishing author characteristics have evolved over time. In addition, the published literature of a field could be considered one repository of the insights and advancements of the field. One would hope that the authors contributing to that literature are a deep and wide reflection of the people working in that field. Analyzing authorship is one way to assess the breadth and depth of contributions from the profession.
The diagnosis of amyloidosis is important for early intervention, disease monitoring, and prevention of complications and progression. Carpal tunnel syndrome (CTS) and trigger digit (TD) are two ...common conditions associated with early disease. The purpose of this study was to define disease prevalence among patients with bilateral CTS and multiple TDs and assess for an increased rate of diagnosis in the presence of both.
Men older than 50 years and women older than 60 years of age diagnosed with bilateral CTS, multiple TDs, or a combination of the 2 were prospectively enrolled in our study. Tenosynovial biopsy samples taken at the time of surgery were tested for the presence of amyloid using Congo red staining. Demographic and medical covariates were also collected and analyzed for differences between amyloid-positive and -negative patients.
Fifty-six patients were enrolled in the study, and nine patients tested positive for amyloid deposition. The demographics and medical comorbidities were similar between amyloid-positive and -negative patients. Thirty patients with bilateral CTS were enrolled, and four tested positive for amyloid. For patients with multiple TDs, a total of 17 patients were enrolled, and 4 tested positive for amyloid. Among patients with multiple TDs, only men tested positive for amyloid and were, on average, younger than those who tested negative (61 and 73 years, respectively). Patients presenting with a combination of CTS and TD did not exhibit increased amyloid discovery.
Hand surgeons should consider tenosynovial biopsy in men older than 50 years and women older than 60 years presenting with either bilateral CTS or multiple TDs.
Prognostic IV.
Testing of Direct Neurorrhaphy Strain Smetana, Brandon S.; Cao, Jue; Merrell, Gregory A. ...
The Journal of hand surgery (American ed.),
July 2019, 2019-Jul, 2019-07-00, 20190701, Letnik:
44, Številka:
7
Journal Article
Recenzirano
To investigate the ideal suture material to test strain at nerve repair sites. Based on nerve strain tolerance, we aimed to determine which suture reliably failed by an average of 5% and a maximum of ...8% strain when loaded to failure.
The median nerve of 19 cadavers was exposed in the distal forearm, transected proximally, and attached to a spring gauge. It was marked 5 cm on either side of its midpoint to measure strain. A laceration was created at its midpoint. We performed a tension-free end-to-end repair with a single epineural suture. Load to failure of the repair site was recorded. We recorded strain at failure and mode of failure (pullout vs breakage). Eight different sutures were tested: 6-0, 8-0, 9-0, and 10-0 nylon; and 6-0, 7-0, 8-0, and 10-0 polypropylene.
Average strain at failure of 9-0 nylon most closely approximated 5% (4.9%). Moreover, 8-0 polypropylene and 10-0 nylon and polypropylene failed with average strains less than 5% and a maximum strain of failure less than 8%. Regardless of type, 6-0 to 8-0 caliber suture failed primarily by pullout of the suture from the epineurium whereas 9-0 and 10-0 nylon and polypropylene failed by suture breakage. Decreased precision through increased variability was seen when testing sutures failing via pullout.
Nylon suture size 8-0 has been advocated as the suggested intraoperative aid to test strain at nerve repair sites. Our study suggests that 9-0 nylon may be a more appropriate testing suture because of its more predictable failure via breakage and its failure by a threshold of 5% to 8% strain. Although 8-0 nylon and polypropylene may also represent reasonable testing sutures, 8-0 nylon failed on average above 5% strain, with strains exceeding 8%, and both failed via the mechanism of pullout.
This study’s findings provide information for surgeons attempting to decide during surgery whether to perform direct nerve repair.
The evolution in surgical technique and suture technology has provided an abundance of options for flexor tendon repairs. Multiple biomechanical studies have attempted to identify the best surgical ...technique based on suture properties, technical modifications, and repair configurations. However, the burgeoning amount of research on flexor tendon repairs has made it difficult to follow, and no gold standard has been determined for the optimal repair algorithm. Therefore, it seems that repairs are usually chosen based on a combination of familiarity from training, popularity, and technical difficulty. We will discuss the advantages, disadvantages, and technical aspects of some of the most common core flexor tendon repairs in the literature. We will also highlight the nomenclature carried through the years, drawings of the repairs referred to by that nomenclature, and the data that support those repairs.
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