Double Fascicular Transfer Using Partially Injured Donor Nerves: Is It Powerful Enough to Restore Elbow Flexion in Acute Brachial Plexus Injuries?

2021 ◽  
Author(s):  
Tommy Nai-Jen Chang ◽  
Johnny Chuieng-Yi Lu ◽  
Che-Hsiung Lee ◽  
Yu-Ching Lin ◽  
Yenpo Lin ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Demographic Data ◽  
Preoperative Evaluation ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Postoperative Rehabilitation ◽  
Strength Assessment ◽  
Group I ◽  
Healthy Side ◽  
Group Ii

Abstract Background Loss of elbow flexion is a common sequela of acute brachial plexus injuries (BPIs). The Mackinnon/Oberlin-II double fascicular transfer (DFT) is a widely used method to restore this function in acute C5–6 or C5–7 injuries. This study attempted to evaluate if this technique can be applied reliably for cases involving C8 and/or T1 injuries. Methods Adult patients with acute BPIs who underwent the Mackinnon/Oberlin-II DFT in our center between 2008 and 2018 were retrospectively identified. Group I (n = 37) included patients with only C5–6 or C5–7 injury, while group II (n = 32) patients presented C5–8 ± T1 injuries. The demographic data, pre- and postoperative neurologic evaluations, electrodiagnostic studies, and grip strength assessment were collected. Results A total of 69 patients met the inclusion criteria. Preoperatively, the patients in group II presented poorer nerve conduction and electromyography in both the median and the ulnar nerves and the supply muscles. The percentage of M3 achievement in both groups was 91.9 versus 87.5% and M4 was 73.0 and 71.9%, respectively, which both were not statically significant but the achievement of group II was slower than the group I, 1 to 2 months slower, respectively. Both groups had 57.57 and 46.0% of the postoperative grip power compared with the healthy side, the result of shoulder abduction was not different (p = 0.480). Conclusion With careful preoperative evaluation, early intervention, appropriate intraoperative functional fascicle selection, and aggressive postoperative rehabilitation, indications for the Mackinnon/Oberlin-II DFT technique can safely include acute C5–8 injuries and even partial T1 acute BPIs.

Analysis of human acellular nerve allograft combined with contralateral C7 nerve root transfer for restoration of shoulder abduction and elbow flexion in brachial plexus injury: a mean 4-year follow-up

2020 ◽  
Vol 132 (6) ◽  
pp. 1914-1924 ◽  
Author(s):  
Liang Li ◽  
Jiantao Yang ◽  
Bengang Qin ◽  
Honggang Wang ◽  
Yi Yang ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Functional Outcomes ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Allograft Reconstruction ◽  
Acellular Nerve Allograft ◽  
The Mean ◽  
Monofilament Test

OBJECTIVEHuman acellular nerve allograft applications have increased in clinical practice, but no studies have quantified their influence on reconstruction outcomes for high-level, greater, and mixed nerves, especially the brachial plexus. The authors investigated the functional outcomes of human acellular nerve allograft reconstruction for nerve gaps in patients with brachial plexus injury (BPI) undergoing contralateral C7 (CC7) nerve root transfer to innervate the upper trunk, and they determined the independent predictors of recovery in shoulder abduction and elbow flexion.METHODSForty-five patients with partial or total BPI were eligible for this retrospective study after CC7 nerve root transfer to the upper trunk using human acellular nerve allografts. Deltoid and biceps muscle strength, degree of shoulder abduction and elbow flexion, Semmes-Weinstein monofilament test, and static two-point discrimination (S2PD) were examined according to the modified British Medical Research Council (mBMRC) scoring system, and disabilities of the arm, shoulder, and hand (DASH) were scored to establish the function of the affected upper limb. Meaningful recovery was defined as grades of M3–M5 or S3–S4 based on the scoring system. Subgroup analysis and univariate and multivariate logistic regression analyses were conducted to identify predictors of human acellular nerve allograft reconstruction.RESULTSThe mean follow-up duration and the mean human acellular nerve allograft length were 48.1 ± 10.1 months and 30.9 ± 5.9 mm, respectively. Deltoid and biceps muscle strength was grade M4 or M3 in 71.1% and 60.0% of patients. Patients in the following groups achieved a higher rate of meaningful recovery in deltoid and biceps strength, as well as lower DASH scores (p < 0.01): age < 20 years and age 20–29 years; allograft lengths ≤ 30 mm; and patients in whom the interval between injury and surgery was < 90 days. The meaningful sensory recovery rate was approximately 70% in the Semmes-Weinstein monofilament test and S2PD. According to univariate and multivariate logistic regression analyses, age, interval between injury and surgery, and allograft length significantly influenced functional outcomes.CONCLUSIONSHuman acellular nerve allografts offered safe reconstruction for 20- to 50-mm nerve gaps in procedures for CC7 nerve root transfer to repair the upper trunk after BPI. The group in which allograft lengths were ≤ 30 mm achieved better functional outcome than others, and the recommended length of allograft in this procedure was less than 30 mm. Age, interval between injury and surgery, and allograft length were independent predictors of functional outcomes after human acellular nerve allograft reconstruction.

Transfer of a Motor Fascicle From the Ulnar Nerve to the Branch of the Radial Nerve Destined to the Long Head of the Triceps for Restoration of Elbow Extension in Brachial Plexus Surgery

Neurosurgery ◽  
2011 ◽  
Vol 70 (2) ◽  
pp. E516-E520 ◽  
Author(s):  
Leandro Pretto Flores
Keyword(s):  
Computed Tomography ◽  
Brachial Plexus ◽  
Ulnar Nerve ◽  
Radial Nerve ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Elbow Extension ◽  
Long Head ◽  
Brachial Plexus Surgery

Abstract BACKGROUND AND IMPORTANCE: Restoration of elbow extension has not been considered of much importance regarding functional outcomes in brachial plexus surgery; however, the flexion of the elbow joint is only fully effective if the motion can be stabilized, what can be achieved solely if the triceps brachii is coactivated. To present a novel nerve transfer of a healthy motor fascicle from the ulnar nerve to the nerve of the long head of the triceps to restore the elbow extension function in brachial plexus injuries involving the upper and middle trunks. CLINICAL PRESENTATION: Case 1 is a 32-year-old man sustaining a right brachial extended upper plexus injury in a motorcycle accident 5 months before admission. The computed tomography myelogram demonstrated avulsion of the C5 and C6 roots. Case 2 is a 24-year-old man who sustained a C5-C7 injury to the left brachial plexus in a traffic accident 4 months before admission. Computed tomography myelogram demonstrated signs of C6 and C7 root avulsion. The technique included an incision at the medial border of the biceps, in the proximal third of the involved arm, followed by identification of the ulnar nerve, the radial nerve, and the branch to the long head of the triceps. The proximal stump of a motor fascicle from the ulnar nerve was sutured directly to the distal stump of the nerve of the long head of the triceps. Techniques to restore elbow flexion and shoulder abduction were applied in both cases. Triceps strength Medical Research Council M4 grade was obtained in both cases. CONCLUSION: The attempted nerve transfer was effective for restoration of elbow extension in primary brachial plexus surgery; however, it should be selected only for cases in which other reliable donor nerves were used to restore elbow flexion.

Clinical findings in C5-C6 and C5-C7 root palsies with brachial plexus traction lesions

2012 ◽  
Vol 38 (3) ◽  
pp. 237-241 ◽  
Author(s):  
J. A. Bertelli ◽  
M. F. Ghizoni
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Clinical Findings ◽  
Hand Strength ◽  
Shoulder Abduction ◽  
Finger Extension ◽  
Root Injury ◽  
Flexion Extension

Stretch injuries of the C5-C7 roots of the brachial plexus traditionally have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. Based on current myotome maps we hypothesized that, as far as motion is concerned, palsies involving C5-C6 and C5-C7 root injuries should be similar. In 38 patients with upper-type palsies of the brachial plexus, we examined for correlations between clinical findings and root injury level, as documented by CT tomomyeloscan. Contrary to commonly held beliefs, C5-C7 root injuries were not associated with loss of extension of the elbow, wrist, thumb, or fingers, but residual hand strength was much lower with C5-C7 vs C5-C6 lesions.

Hormonal status of patients after surgical treatment of fibrocystic mastopathy and possibilityes of its corrections

2017 ◽  
pp. 128-131
Author(s):  
Yu.Ya. Pryshash ◽  
Keyword(s):  
Surgical Treatment ◽  
Standard Dose ◽  
Treatment Phase ◽  
Nodule Formation ◽  
Double Dose ◽  
Postoperative Rehabilitation ◽  
Group Iii ◽  
Group I ◽  
Group Ii ◽  
High Doses

The purpose of the study was to investigate the efficacy of Mastodynon in terms of indications in elevated doses versus the standard dose. Materials and methods. Data were analyzed for 60 patients after surgical treatment of fibro-cystic mastopathy. Depending on the postoperative therapy received by the patients, they were divided into three groups. Group I (n = 20): patients were observed in accordance with the standards established in mammal practice and did not receive special agents that affect hormonal homeostasis. Group II (n = 20): In addition to observation, patients received Mastodynon® (1 tablet or 30 drops 2 times a day) for 6 months. Group III (n = 20): Patients were given for a post-operative rehabilitation Mastodynon® in a double dose (2 tablets or 60 drops 2 times a day) for 6 months. Results Surgical treatment without conservative therapy eliminates organic changes in the thoracic glands (GH), but hormonal disorders that have led to pathologic and histological changes in the tissues of GZ continue to exist for a long time and can lead to repeated nodal formations. In group І, 25% of patients within 2 years performed repeated sectoral resections on recurrence of nodule formation. In group І, 25% of patients within 2 years performed repeated sectoral resections on recurrence of nodule formation. The use of Mastodynon® in standard doses (group II) for postoperative rehabilitation contributes to a significant improvement in hormonal homeostasis (normalization of prolactin, estradiol and progesterone levels), a 24.7 mm decrease in the degree of cyclic mastodynia according to the visual analog scale (VAS), and the improvement of ultrasound scan Pictures of GZ in 75% of patients. The most pronounced effect of this rehabilitation approach after the surgical treatment phase was noted for the use of Mastodynone in doble doses (2 tablets or 60 drops 2 times a day) in Group III. In these patients, the degree of reduction of cyclic mastodynia was 30 mm for VAS and positive changes in the tissues of GH were noted in 85% of patients. However, the highest incidence of adverse events was also noted in Group III, although they were temporary in nature and did not require withdrawal or dose reduction. Conclusion. Despite the presence of short-term side effects and rapid rebounding in the double-dose Mastodynon® group, our study showed better results than standard doses, faster and more stable therapeutic effect. Taking into account the results obtained, it can be argued that the use of high doses of Mastodynon® may be recommended to patients for the treatment of mastopathy. For a more complete study of such an important aspect as the tolerability of high doses of Mastodynon®, it is advisable to conduct more extensive studies, taking into account the dosage form and the use of other drugs. Key words: mastopathy, postoperative rehabilitation, Mastodynon®, mastodynia.

scholarly journals Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques

2015 ◽  
Vol 122 (1) ◽  
pp. 195-201 ◽  
Author(s):  
Zarina S. Ali ◽  
Gregory G. Heuer ◽  
Ryan W. F. Faught ◽  
Shriya H. Kaneriya ◽  
Umar A. Sheikh ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Controlled Trial ◽  
Treatment Strategies ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Surgical Approaches ◽  
Shoulder Abduction ◽  
Nerve Grafting ◽  
Nerve Transfers ◽  
Repair Techniques

OBJECT Adult upper trunk brachial plexus injuries result in significant disability. Several surgical treatment strategies exist, including nerve grafting, nerve transfers, and a combination of both approaches. However, no existing data clearly indicate the most successful strategy for restoring elbow flexion and shoulder abduction in these patients. The authors reviewed the literature to compare outcomes of the three surgical repair techniques listed above to determine the optimal approach to traumatic injury to the upper brachial plexus in adults. METHODS Both PubMed and EMBASE databases were searched for English-language articles containing the MeSH topic “brachial plexus” in conjunction with the word “injury” or “trauma” in the title and “surgery” or “repair” as a MeSH subheading or in the title, excluding pediatric articles and those articles limited to avulsions. The search was also limited to articles published after 1990 and containing at least 10 operated cases involving upper brachial plexus injuries. The search was supplemented with articles obtained through the “Related Articles” feature on PubMed and the bibliographies of selected publications. From the articles was collected information on the operation performed, number of operated cases, mean subject ages, sex distribution, interval between injury and surgery, source of nerve transfers, mean duration of follow-up, year of publication, and percentage of operative success in terms of elbow flexion and shoulder abduction of the injured limb. The recovery of elbow flexion and shoulder abduction was separately analyzed. A subanalysis was also performed to assess the recovery of elbow flexion following various neurotization techniques. RESULTS As regards the restoration of elbow flexion, nerve grafting led to significantly better outcomes than either nerve transfer or the combined techniques (F = 4.71, p = 0.0097). However, separating the Oberlin procedure from other neurotization techniques revealed that the former was significantly more successful (F = 82.82, p < 0.001). Moreover, in comparing the Oberlin procedure to nerve grafting or combined procedures, again the former was significantly more successful than either of the latter two approaches (F = 53.14; p < 0.001). In the restoration of shoulder abduction, nerve transfer was significantly more successful than the combined procedure (p = 0.046), which in turn was significantly better than nerve grafting procedures (F = 5.53, p = 0.0044). CONCLUSIONS According to data in this study, in upper trunk brachial plexus injuries in adults, the Oberlin procedure and nerve transfers are the more successful approaches to restore elbow flexion and shoulder abduction, respectively, compared with nerve grafting or combined techniques. A prospective, randomized controlled trial would be necessary to fully elucidate differences in outcome among the various surgical approaches.

scholarly journals Targeted fascicular biopsy of the brachial plexus: rationale and operative technique

2017 ◽  
Vol 42 (3) ◽  
pp. E9 ◽  
Author(s):  
Pierre Laumonerie ◽  
Stepan Capek ◽  
Kimberly K. Amrami ◽  
P. James B. Dyck ◽  
Robert J. Spinner
Keyword(s):  
Brachial Plexus ◽  
Operative Technique ◽  
Diagnostic Yield ◽  
Demographic Data ◽  
Neuromuscular Disorders ◽  
Preoperative Evaluation ◽  
Nerve Biopsy ◽  
Definitive Treatment ◽  
Targeted Biopsy ◽  
Initial Procedure

OBJECTIVE Nerve biopsy is useful in the management of neuromuscular disorders and is commonly performed in distal, noncritical cutaneous nerves. In general, these procedures are diagnostic in only 20%–50%. In selected cases in which preoperative evaluation points toward a more localized process, targeted biopsy would likely improve diagnostic yield. The authors report their experience with targeted fascicular biopsy of the brachial plexus and provide a description of the operative technique. METHODS All cases of targeted biopsy of the brachial plexus biopsy performed between 2003 and 2015 were reviewed. Targeted nerve biopsy was performed using a supraclavicular, infraclavicular, or proximal medial arm approach. Demographic data and clinical presentation as well as the details of the procedure, adverse events (temporary or permanent), and final pathological findings were recorded. RESULTS Brachial plexus biopsy was performed in 74 patients (47 women and 27 men). The patients' mean age was 57.7 years. All patients had abnormal findings on physical examination, electrodiagnostic studies, and MRI. The overall diagnostic yield of biopsy was 74.3% (n = 55). The most common diagnoses included inflammatory demyelination (19), breast carcinoma (17), neurolymphomatosis (8), and perineurioma (7). There was a 19% complication rate; most of the complications were minor or transient, but 4 patients (5.4%) had increased numbness and 3 (4.0%) had additional weakness following biopsy. CONCLUSIONS Targeted fascicular biopsy of the brachial plexus is an effective diagnostic procedure, and in highly selected cases should be considered as the initial procedure over nontargeted, distal cutaneous nerve biopsy. Using MRI to guide the location of a fascicular biopsy, the authors found this technique to produce a higher diagnostic yield than historical norms as well as providing justification for definitive treatment.

Clinical Results of Contralateral C7 Root Neurotization to the Median Nerve in Brachial Plexus Injuries with Total Root Avulsions

1999 ◽  
Vol 24 (5) ◽  
pp. 556-560 ◽  
Author(s):  
S. WAIKAKUL ◽  
S. ORAPIN ◽  
V. VANADURONGWAN
Keyword(s):  
Brachial Plexus ◽  
Median Nerve ◽  
Motor Function ◽  
Anterior Part ◽  
Elbow Flexion ◽  
Clinical Results ◽  
Suprascapular Nerve ◽  
Nerve Graft ◽  
Sensory Function ◽  
Shoulder Abduction

This prospective study was carried out to assess motor and sensory recovery after contralateral C7 root to median nerve neurotization in brachial plexus injuries with total root avulsions. The survey was carried out from 1993 to 1995 and the patients were followed up for at least 3 years. There were 96 male patients with ages ranging from 13 to 48 years. All had a unilateral brachial plexus injury with avulsion of all roots. This was confirmed by clinical assessment and exploration. The anterior part of the contralateral C7 root was used for neurotization via a reversed pedicular ulnar nerve graft and the proximal end of the graft was connected to the median nerve. Furthermore, phrenic nerve to suprascapular nerve and spinal accessory nerve (via a sural nerve graft) to musculocutaneous nerve neurotizations were also carried out to obtain shoulder abduction and elbow flexion. At the 3 year follow-up, most patients had encouraging recovery of sensory function in the hand but motor function of the forearm and hand muscles was rather poor. Acceptable motor function was found in only 50 to 60% of the patients who were younger than 18 years.

scholarly journals Pronator Quadratus to Extensor Carpi Radialis Brevis Nerve Transfer in C5–C7 or C5–C8 Brachial Plexus Injuries for Independent Wrist Extension

2020 ◽  
Vol 53 (01) ◽  
pp. 036-041
Author(s):  
Anil Bhatia ◽  
Mahmoud Salama
Keyword(s):  
Brachial Plexus ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Wrist Extension ◽  
Pronator Quadratus ◽  
Motor Branch ◽  
Nerve Surgery ◽  
Extensor Carpi Radialis

Abstract Background Patients with lesions affecting C7 and C8 roots (in addition to C56) demonstrate loss of independent wrist dorsiflexion in addition to loss of shoulder abduction and elbow flexion. Traditionally, this deficit has been addressed using tendon transfers after useful function at the shoulder and elbow has been restored by primary nerve surgery. Confidence with nerve transfer techniques has prompted attempts to replace this method by incorporating procedures for wrist dorsiflexion in the primary operation itself. Aim The objective of this study was to report the results of pronator quadratus motor branch transfers to the extensor carpi radialis brevis motor branch to reconstruct wrist extension in C5–C8 root lesions of the brachial plexus. Patients and Methods Twenty-three patients, average age 30 years, with C5–8 root injuries underwent operations an average of 4.7 months after their accident. Extrinsic extension of the fingers and thumb was weak or absent in two cases while the remaining 18 patients could open their hand actively. The patients lacked independent wrist extension when they were examined with the fingers flexed as the compensatory action of the extrinsic finger extensors was removed. The average follow-up was 21 months postoperative with the minimal follow-up period was at least 12 months. Results Successful reinnervations of the extensor carpi radialis brevis (ECRB) were demonstrated in all patients. In 17 patients, wrist extension scored M4, and in 3 patients it scored M3. Conclusions The pronator quadratus (PQ) to ECRB nerve transfer in C5–C7 or C5–C8 brachial plexus injuries for independent wrist extension reconstruction gives consistently good results with minimal donor morbidity.

Distal Metatarsal Segmental Shortening for the Treatment of Chronic Metatarsophalangeal Dislocation of Lesser Toes

2020 ◽  
pp. 107110072096108
Author(s):  
Tzu-Cheng Yang ◽  
Yun-Hsuan Tzeng ◽  
Chien-Shun Wang ◽  
Ming-Chau Chang ◽  
Chao-Ching Chiang
Keyword(s):  
Demographic Data ◽  
Level Of Evidence ◽  
Radiographic Measurements ◽  
Group I ◽  
Significant Difference ◽  
Scale Scores ◽  
Group Ii ◽  
American Orthopaedic ◽  
Retrospective Comparative Study ◽  
Mtp Joints

Background: This retrospective study aimed to describe the techniques and results of distal metatarsal segmental shortening (DMSS) for the treatment of chronic irreducible metatarsophalangeal (MTP) dislocation of lesser toes. Methods: We retrospectively reviewed patients who underwent DMSS for chronic dislocation of MTP joints of lesser toes between January 2010 and December 2017 with follow-up of at least 24 months. Demographic data, radiographic measurements, functional outcomes, and complications were analyzed. Furthermore, the results of patients with short segment of shortening (group I, <10 mm) were compared to those with long segment of shortening (group II, ≥10 mm). A total of 43 MTP joints of 30 patients with an average age of 70.4 years were included. Results: Union was observed in 42 metatarsals (97.7%). Mean American Orthopaedic Foot & Ankle Society scale scores improved significantly from 42.2 (range, 15-65) preoperatively to 79.1 (range, 52-90) ( P < .001). Mean visual analog scale pain score improved significantly from 5.0 (range, 1-9) preoperatively to 1.8 (range, 0-6) ( P < .001). Complications included 1 nonunion, 1 osteonecrosis, 3 metatarsal angulation, 4 recurrent instability, 4 symptomatic osteoarthritis, 3 transfer metatarsalgia, and 1 floating toe. Group I included 23 MTP joints and group II included 20 MTP joints. There was no significant difference in clinical outcomes and complications between the 2 groups. Conclusion: DMSS was a reliable procedure for the treatment of chronic irreducible dislocated MTP joint of lesser toes. It provided satisfactory surgical outcomes and a low rate of postoperative complications, regardless of length of metatarsal shortening. Level of Evidence: Level III, retrospective comparative study.

A CLINICAL COMPARISON BETWEEN 0.5% BUPIVACAINE AND 0.5% BUPIVACAINE DEXAMETHASONE 8mg COMBINATION IN BRACHIAL PLEXUS BLOCK BY SUPRACLAVICULAR APPROACH

2021 ◽  
pp. 18-20
Author(s):  
Bonthu Mounica ◽  
Palle Krishna Padma Sri ◽  
K. Madhusudhan Reddy
Keyword(s):  
Brachial Plexus ◽  
Upper Limb ◽  
Brachial Plexus Block ◽  
Single Shot ◽  
Motor Blockade ◽  
Duration Of Action ◽  
Group I ◽  
Prolonged Duration ◽  
Group Ii ◽  
Plexus Block

Aim:To study the onset and duration of sensory and motor blockade Introduction: Brachial plexus block provides a useful alternative to general anaesthesia for upper limb surgeries. Bupivacaine is one of the most frequently used local anaesthetic which has a longer duration of action of 3 to 8 hours but has drawbacks of delayed onset and patchy analgesia. Dexamethasone is a very potent glucocorticoid with very good anti-inammatory and analgesic activity. Materials and methods: A prospective, randomised single-blinded study was undertaken in patients posted for upper limb surgeries under the supraclavicular block. 60 patients with ASA class I and II were randomly grouped into two groups. Group I received 30ml bupivacaine 0.5% and Group II received a combination of 28ml bupivacaine 0.5% and 2ml dexamethasone 8mg. 30ml solution is used for a single shot blockade of supraclavicular brachial plexus. Results: Group II patients had a faster onset of action and prolonged duration of action. Discussion: The addition of dexamethasone 8mg to bupivacaine 0.5% speeds the onset of sensory and motor blockade also prolongs the duration thus provides better analgesia and reduces the requirements of rescue analgesics. Conclusion:Acombination of bupivacaine 0.5% and dexamethasone 8mg has a signicantly faster onset and prolonged duration of action.

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